Lembit �pik: Is the Minister aware that cross-border pressures will increase if Llanidloes hospital is closed, with an even greater burden placed on the ambulance service as a direct result of reduced health care in the Llanidloes area? Will he discuss with Assembly Ministers the consequences of such a closure, to avert those potentially devastating effects on health provision in south Montgomeryshire, which simply cannot be mitigated through alternative provision elsewhere in Powys or Shropshire?

Paul Flynn: How many(a) police civilian staff, (b) police officers and (c) community support officers there are in Wales.

Paul Flynn: That is an unsatisfactory situation. Is not it disturbing that the figures for Scotland are superior in every way to those for Wales and England? Of course, Scotland missed out, happily, on the chaotic futility and waste of the police reorganisations attempted last year. Should not the Secretary of State support the suggestion made by Rosemary Butler, the Assembly Member for Newport, West, that the Welsh police forces should come under the Welsh Assembly? Is not it discourteous of him to dismiss that suggestion with his fatwa?

Elfyn Llwyd: The Minister will know that there has been a long-running campaign to have a prison facility to serve north and mid-Wales, because at any given time between 650 and 750 people are held elsewhere in English jails. Will he please intervene as soon as possible, because there is some talk of putting yet another prison facility in Cwmbran, Gwent? The people of Cwmbran do not want it. The right hon. Member for Torfaen (Mr. Murphy) does not want it. We desperately need a facility for north and mid-Wales. Will the Minister please intervene personally in this debate?

Cheryl Gillan: May I start by associating Conservative Members with the remarks of the Secretary of State concerning the sad loss of Peter Clarke, the Children's Commissioner for Wales?
	Given the revelation that almost half the antisocial behaviour orders in Wales are being breached and13 registered sex offenders are unaccounted for, there is an obvious failure in offender management. With dangerously overcrowded prisons in south Wales and no prisons in north Wales, and with that now coupled with changes to the probation service, does the Minister agree that the new offender managers will have increasing problems in managing Welsh offenders so as to ensure adequate public protection?

Peter Hain: The hon. Gentleman speaks from the Conservative Benches, yet the Conservatives have consistently opposed every measure that this Government have introduced to clamp down on illegal asylum applications and illegal immigration. The latest figures show that every half hour24 hours a day,365 days a yearsomebody is removed. When the Tory party starts supporting the Government in the action that we take to remove illegal immigrants, perhaps the hon. Gentleman will be entitled to ask me such a question.

Tony Blair: Before I list my engagements, I am sure that the whole House willjoin me in sending our condolences to the familyand friends of Private Luke Simpson from the1st Battalion, the Yorkshire Regiment, who died in Iraq during the parliamentary recess. He was a very professional soldier who was performing a vital role in working towards a safer and more secure world. We pay tribute to him today.
	I have had meetings with ministerial colleagues and others. In addition to my duties in the House, I shall have further such meetings later today.

Tony Blair: As my hon. Friend rightly pointed out, I met her over the closure in her constituency and I again extend my sympathy to those in the work force and their families who were affected by it. As she rightly said, prompt action was taken by the Scottish Executive, the Government and the local job centre to ensure that we had the right measures in place to help those people find new jobs. She is also right to say that our task now is to build on the huge economic success that Scotland has had over the past few years, with 200,000 extra jobs, and ensure that we provide full employment, which she wants to see and I believe is now possible.

David Cameron: I join the Prime Minister in paying tribute to Private Luke Simpson who died in Iraq 12 days ago. He died serving our country.
	There are 125,000 people in our country who have paid into company pension schemes, seen them collapse, and been left with little or nothing. Today, the Government were defeated in the courts and ordered to look again at how they have responded to the real crisis at the heart of our pension system. Does the Prime Minister agree that there is real strength of feeling on both sides of the House that those people have not been treated fairly and will he now look at working on a cross-party basis [ Interruption. ] Yes, let us sort this out on an affordable and sustainable basis. Will he do that?

David Cameron: The Prime Minister talks specifically about the financial assistance scheme, but is it not becoming increasingly clear that it simply is not working properly? Of the 125,000 people who have been left with little or nothing, only 900 have received any money, a year after the ombudsman reported. Does not the Prime Minister agree that that is completely inadequate and will he confirm those figures for us?

David Cameron: The point is that the money is not getting through to the people who need it. Given that the financial assistance scheme is not working and that an increasing number of pension experts recognise that, will the Prime Minister at least look at ideas that would not cost taxpayers money, such as pooling the scheme funds and rolling the administration of the financial assistance scheme, which is not working properly, into the Pension Protection Fund? Will he also look at unclaimed pension assets? The fact is that those pensioners lost their money under his watch and he has time now to do something about it.  [ Interruption. ] Yes. So will he agree [ Interruption. ] He shakes his head, but these people lost their pensions partly because of the 5 billion pension raid that the Chancellor has carried out every year. The Prime Minister can use his last few months in office to grandstand, or he can do something for those people. So, will he meet the pensioners and their representatives and, on a cross-party basis, sort this out?

Tony Blair: We have just had a pretty good example of grandstanding, if I may say so. I thought that the right hon. Gentleman began this question not simply to make a political point of it, but the fact of the matter is that the pension mis-selling under the Conservative Government was absolutely legendary and the only compensation is the compensation that we have given. It is also not true to say that the assistance scheme is not working. It is of course for people who are going to become pensioners in the future. We are perfectly prepared to sit down and look at what more we can do, but in the end, it will come down to money. The other day, the shadow Chancellor was asked in specific terms whether he would commit more money to pensions. He said that there are people in the Conservative party who asking them to
	put more money into the pensions.
	and that they have to resist those demands.

Ashok Kumar: Is my right hon. Friend aware of a local campaign in Middlesbrough calling for a ban on the sale of bladed weapons? The campaign has been organised by Mothers Against Knives and has the support of 5,000 people, including the mayor of Middlesbrough, Ray Mallon, and the former leader of the Conservative party, the right hon. and learned Member for Folkestone and Hythe (Mr. Howard). Given that there is so much support, will my right hon. Friend use his good office to try to ensure that we ban the sale of bladed weapons?

David Cameron: So why does he think that all the people who want to be Deputy Prime Minister have to trash his record and lurch to the left?

Tony Blair: I do not, as a matter of fact. I would just like to draw attention[Hon. Members: Answer!] Since we are discussing what members of our parties say their about their leaders, let me quote what the hon. Member for Gainsborough (Mr. Leigh) said last week:
	This is the year that Conservative spokesmen have adopted Aneurin Bevan as a role model ... praised left-wing Polly Toynbee's view of society; snubbed the CBI; pleaded understanding for marauding hoodies.
	When the right hon. Member for Witney (Mr. Cameron) cannot even make up his mind about whether his role model is Polly Toynbee or Margaret Thatcher, he should not be lecturing mehe should take some lessons himself.

Gordon Prentice: My friend is a great champion of the private sector and wants to give it a much bigger role in the NHS in Lancashire and Cumbria, and the South African company, Netcare, is to carry out work in six specialtiesgynaecology, urology, orthopaedics, rheumatology, ear, nose and throat and general surgery. Will he explain to my constituents and to me why the contract is to be regarded as commercially confidential? How can that possibly be justified, and if it is secret, how will we know that we are not being ripped off?

Tony Blair: The contracts that are entered into by the national health service with a range of different private contractors are commercially confidential. The reason why they have been introduced, and why we have got the independent sector working alongside the national health service, is that for many of the things that my hon. Friend lists, it is actually cutting waiting times, improving the quality of care, and giving us the possibility of creating a national health service that is fit for the early 21st century. The reason why, for example, in the past few months we have managed for the first time to get in-patient and out-patient average waiting times down to a few weeks is precisely that combination of investment and reform. It is creating the national health service that we want to see, so I suggest that my hon. Friend supports it.

Tony Blair: I certainly agree with the first part of the question; it is important that those who are still in fear of returning to their homes are able to do so. Where I disagree with him profoundly is on any notion that the intervention in Kosovo was anything other than successful. Of course, we have still got to sort out the ongoing constitutional status of Kosovo, but as a result of what has happened in Kosovo, and as a result of that intervention, the whole of the Balkans is a changed region. We have proper democratic elections in Serbia; Croatia is now a candidate to become a member of the European Union; and for the first time in round about 100 years, there is the prospect of peace in the Balkans, with, of course, if his party does not mind me saying so, the prospect of future European Union membership as a tremendous bonus for the countries as they make progress. I totally agree that there are still many things to be done, in Kosovo and elsewhere in the Balkans, but I have to say that I believe that our intervention in Kosovo was necessary and right, and has given the Balkans the prospect of a decent future.

Lyn Brown: In light of the recent firearm murders in the capital, will the Prime Minister join me in condemning that evil, and in congratulating the Mayor of London for placing more police on the street? Will he ensure that the Government re-examine the real and entrenched poverty in London, so that we make sure that we remain tough on the causes of crime, as well as on crime itself?

Tony Blair: First, I absolutely agree with my hon. Friend that it is a tribute to the Mayorand, I think, to the Government as wellthat there are extra numbers of police and community support officers patrolling the streets, and that there have been very significant falls in crime recently in Londondespite, obviously, the recent terrible events. She is completely right, too, in saying that we have got to carry on reducing poverty in the country, but there are some2.5 million fewer people in relative poverty than there were some years back, and the inner-city regeneration programmes in her communities and elsewhere are playing a real part in doing that. We have to continue with that, and we have to take the specific measures necessary, within specific criminal cultures, to deal with those who, as we have seen recently and all too tragically, are engaged in gun violence.

Tony Blair: Whatever the level of investment, each trustand this is the whole point about making sure that we have proper financial transparency in the health servicemust live within its means. There has been a massive increase in investment, and as a result, waiting lists have fallen dramatically in the hon. Gentleman's area, as in others; cancer treatment has improved; cardiac treatment has improved; and accident and emergency treatment has improved. Despite all of that, it is correct that trusts must live within their financial meansI am afraid that that is the case, no matter what amount of money goes in, and it is a lesson that the Liberal Democrats must learn.

Tony Blair: I can certainly assure my hon. Friend that we have no proposals at all to change the Barnett formula which, as he rightly said, has delivered substantial investment for Scotland. The other reason why investment is going into Scotland is the strength of the economy which, whatever the formula, allows an additional amount of money to go into health and education services, and provides help for people in Scotland, not least pensioners. I can assure him that the Barnett formula and the strong economy will continue under a Labour Government and a Labour Executive.

Patrick Cormack: I wonder if someone who has been putI hope temporarily and certainly unwillinglyin the departure lounge can ask someone who already has his boarding ticket what he expects and hopes to be remembered for before he goes off on the lecture circuit?

Kerry McCarthy: Bristol has the second highest number of drug addicts in treatment in the country, but in the past year was given only 639 per addict in treatment, compared with cities like Birmingham, which got nearly three times as much. Can the Prime Minister assure me that the very welcome recent 40 per cent. increase in funding for next year will not be a one-off and that we can look forward to future increases, so that Bristol gets the funding that it deserves to treat the serious drug problem in the city?

Tony Blair: I do not believe that we have gone back on any of the undertakings that we have given. What is extremely important, however, is that we have such a register, because not only will it help us to tackle crime, terrorism and illegal immigration, but an identity card scheme, with the new technology available and the vast bulk of the cost will be spent on passports, anywaywill allow consumers to access better private sector services as well. The Tory opposition to ID cards is regressive, old-fashioned and out of date.

Tony Blair: With permission, I shall make a statement on recent developments in Iraq and across the middle east.
	Saddam Hussein was removed from power in May 2003. In June 2004, the United Nations Security Council passed a resolution setting out the support of the international community for the incoming interim Government of Iraq, for a political process leading to full democratic elections overseen by the United Nations itself, and for Iraq's reconstruction and development after decades of oppression and impoverishment under Saddam's dictatorship.
	In January 2005 the first elections were held for a transitional national assembly, and 7 million people voted. A new constitution was agreed. In December 2005 full parliamentary elections were held, and12 million Iraqis voted. May 2006 saw the forming of the first fully elected Government of Iraq, an expressly non-sectarian Government including all the main elements of Iraqi society, Shi'a, Sunni and Kurdish. There has been full United Nations backing throughout for the political process and now for the Government of Prime Minister Maliki.
	Successive United Nations resolutions have given explicit approval for the presence of the multinational force. The political process has thus continued through the years. For example, as we speak the Iraqi Parliament is awaiting the report on amending the constitution from the constitutional review committee, a draft law on de-Ba'athification relaxing some of the restrictions on former Ba'ath party members, and the new hydrocarbon legislation, which will attempt to spread fairly and evenly the proceeds of Iraq's considerable oil wealth.
	However, the political processthe reconstruction, reconciliation and everything that the UN has set out as the will of the international community and for which Iraqis have votedhas been thwarted or put at risk by the violence and terrorism that have beset the country and its people. From the day of the appalling terrorist outrage in August 2003, which killed the United Nations special representative and many of his colleagues, to this day, Iraq, and Baghdad in particular, has been subject to a sickening level of carnage, some of it aimed at the multinational force but much of it aimed deliberately to provoke a sectarian struggle between Sunni and Shi'a. The bombing of the shrine at Samarra in February 2006 was designed precisely to provoke Shi'a death squads to retaliate against Sunni.
	The violence comes from different sources. Some of it originates with former Saddamists; some with Sunnis who are worried that they will be excluded from the political future of Iraq. Many of the so-called spectacular suicide bombings are the work of al-Qaeda, whose grisly presence in Iraq since 2002 has been part of its wider battle with the forces of progress across the world. Now Shi'a militant groups such as Jaish-al-Mahdi are responsible for the abduction and execution of innocent Sunni. These groups have different aims and ideologies, but one common purpose: to prevent Iraqis' democracy from working.
	Throughout all the wretched and inexcusable bloodshed, one hope remains. Talk to anyone in Iraq of whatever denomination, whether they are Iraqi or part of the multinational force, whether civilian or military, and they all say the same thing: the majority of Iraqis do not want it to be like this. They voted despite the violence, they know its purpose and its effect and they hate both. There can be legitimate debate about what was right and what was wrong in respect of the original decision to remove Saddam. There can be no debate about the rights and wrongs of what is happening in Iraq today. The desire for democracy is good; the attempt to destroy it through terrorism is evil. Unfortunately, that is not the question. The question is not should we, but can we defeat this evil, and do we have a plan to succeed?
	Since the outset, our plan, agreed by Iraq and the United Nations, has been to build up Iraqi capability in order to let Iraqis take control of their own destiny, and that as they would step up, we would increasingly step back. For three years, therefore, we have been working to create, train and equip Iraqi security forces capable of taking on the security of the country themselves.
	In normal circumstances, the progress would be considered remarkable. There are now 10 divisions of the new Iraqi army and more than 130,000 soldiers, able in significant parts of the country to provide order. There are 135,000 personnel in the Iraqi police service. There, the progress has been more constrained, and frequently hampered by corruption and sectarianism, but none the less, again, in normal circumstances, it would be considered a remarkable effort. The plan of General Petraeus, then an army commander in Iraq and now head of the coalition forces there, which was conceived in 2004, has in its essential respects been put in place.
	But these are not normal circumstances. The Iraqi forces have often proved valiant, but the various forces against them have also redoubled their efforts. In particular, in and around Baghdad, where 80 to 90 per cent. of the violence is centred, they have engaged in a systematic attempt to bring the city to chaos. It is the capital of Iraq. Its strategic importance is fundamental. There has been an orgy of terrorism unleashed upon it in order to crush any possibility of its functioning. It does not much matter if elsewhere in Iraq, not least in Basra, change is happening. If Baghdad cannot be secured, the future of the country is in peril. The enemies of Iraq understand that, and we understand it.
	So last year, in concert with our allies and the Iraqi Government, a new plan was formulated, and promulgated by President Bush in January this year. The purpose is unchanged. Indeed, there can be only one purpose in Iraqto support the Government and people of the country to attain the necessary capability to run their own affairs as a sovereign independent state. However, the means of achieving the purpose were adjusted to meet the changing nature of the threat. The Baker-Hamilton report, to which I pay tribute, also informed the strategy.
	There are three elements to this plan. First, there is the Baghdad security initiative, drawn up by Prime Minister Maliki and currently under way. It aims, as the operation in Basra has done, to take the city district by district, drive out the extremists, put the legitimate Iraqi forces in charge and then make it fit for development with a special fund in place able to deliver rapid improvement. This began last Tuesday. It is far too early to tell its results, although early indications are more promising than what was tried unsuccessfully some months back. In particular, there is no doubt of its welcome among ordinary people in Baghdad.
	The second part of the plan is a massive effort to gear up the capability of the Iraqi forces, to plug any gaps in command, logistics, training and equipment. Thirdly, there is a new and far more focused effort on reconciliation, reconstruction and development. There are now talks between Iraqi officials and both Sunni and Shi'a elements that have been engaged in fighting. It is again too early to draw conclusions, but this is being given a wholly different priority within the Iraqi Government and by the multinational force.
	In addition, there have been changes made by Prime Minister Maliki, to whose leadership I again pay tribute, to the way in which economic development and reconstruction moneys are administered within the Iraqi Government, with the Deputy Prime Minister, Barham Salih, given specific responsibility. That will allow the disbursement of funds to be made and will allow, in Baghdad and elsewhere, development and reconstruction to follow closely on the heels of improved security.
	The objective of all this is to show the terrorists that they cannot win, to show those who can be reconciled that they have a place in the new Iraq, and to show the Iraqi people that, however long it takes, the legitimate Iraqi Government whom they elected, and whom the international community support, will prevail.
	The aim of the additional US forces announced by President Bush is precisely to demonstrate that determination. If the plan succeeds, then of course the requirement for the multinational force reduces, including in Baghdad. It is important to showparticularly to show the Iraqi peoplethat we do not desire our forces to remain for any longer than they are needed, but, while they are needed, that we will be at their side. In this context, what is happening in Basra is of huge importance. Over the past months, we have been conducting an operation in Basra, with the 10th division of the Iraqi army, to reach the stage where Basra can be secured by the Iraqis themselves.
	The situation in Basra is very different from that in Baghdad. There is no Sunni insurgency and no al-Qaeda base. There is little Shi'a on Sunni violence. The bulk of the attacks are on the multinational force. It has never presented anything like the challenge in Baghdad. That said, British soldiers are under regular, and often intense fire from extremist groups, notably elements of Jaish-al-Mahdi. I would like, as I have often done in this House, to pay my profound respect to the British armed forces. Whatever views people have about Iraq, our forces are dedicated, professional, committed and brave beyond belief. This country can be immensely proud of them, and we send again our wholehearted sympathy to the families of those who have fallen and to the injured and their families.
	As a result of the operation in Basra, which is now complete, the Iraqi forces now have the primary role for security in most parts of the city. It is a still a difficult and sometimes dangerous place, but many extremists have been arrested or have left the city. The reported levels of murder and kidnapping are significantly down. Surveys of Basrawis after the operations have been conducted show a much greater sense of security. Reconstruction is now happening in schools and health centres; in fact, there are about 300 projects altogether.
	A few days ago, the Deputy Prime Minister, Barham Salih, organised the Basra development forum. He announced a $200 million programme of development and infrastructure in public services. In addition, the international community, with Britain in the lead, has developed projects to increase power supply, put in place proper sewerage systems and increased the supply of drinking water to thousands of homes. The plan to develop Basra port will be published later this year. The problems remain formidable, not least in providing work where for decades 50 per cent. or more of the city's inhabitants have been unemployed. In an extraordinary development, the Marsh Arabs, driven from one of the world's foremost ecological sites by Saddam, have been able to resettle there.
	What all this means is not that Basra is how we want it to be, but it does mean that next chapter in Basra's history can be written by the Iraqis. I have discussed this with Prime Minister Maliki, and our proposals have his full support and, indeed, represent his wishes.
	Already we have handed over prime responsibility for security to the Iraqi authorities in al-Muthanna and Dhi Qar. Now in Basra over the coming months we will transfer more of the responsibility directly to Iraqis. I should say that none of this will mean a diminution in our combat capability. The actual reduction in forces will be from the present 7,100itself down from more than 9,000 two years ago and 40,000 at the time of the conflictto roughly 5,500. However, with the exception of forces which will remain at Basra palace, the British forces will be located at Basra airbase and be in a support role. They will transfer the Shaibah logistics base, the old state building and the Shatt al-Arab hotel to full Iraqi control.
	The British forces that remain in Iraq will have the following tasks: training and support to Iraqi forces; securing the Iraq-Iran border; securing supply routes; and, above all, the ability to conduct operations against extremist groups and to be there in support of the Iraqi army when called upon. Over time, and depending naturally on progress and the capability of the Iraqi security forces, we will be able to draw down further, possibly to below 5,000 once the Basra palace site has been transferred to the Iraqis in late summer.
	We hope that Maysan province can be transferred to full Iraqi control in the next few months, and Basra in the second half of the year. The UK military presence will continue into 2008, for as long as we are wanted and have a job to do. Increasingly, our role will be support and training and our numbers will be able to reduce accordingly.
	Throughout the whole of that part of the south-east, the UK depends on the steadfastness of our coalition partners: Denmark, Australia, Romania, the Czech Republic and Lithuania. I pay tribute to them. I welcome the continuing Australian role at Tallil in Dhi Qar province. We are keeping in close touch with our allies as the transition proceeds.
	The speed at which that happens depends partly on what we do and what the Iraqi authorities do, but also on the attitude of those whom we are, together, fighting. Their claim to be fighting for the liberation of their country is a palpable lie. They know perfectly well that if they stop the terror, agree to let the UN democratic process work and allow the natural talent and wealth of the country to emerge, Iraq would prosper and we could leave. It is precisely their intent to eliminate such a possibility.
	In truth, this is part of a wider struggle that is taking place across the region. The middle east faces an epochal struggle between the forces of progress and those of reaction. The same elements of extremism that try to submerge Iraqor, for that matter, Afghanistanstand in the way of a different and better future throughout the region.
	None of that absolves us from our responsibility. Indeed, for too long, we believed that, provided that regimes were on our side, what they did to their own people was their business. We must never forget that Saddam inflicted 1 million casualties in the Iran-Iraq war and butchered hundreds of thousands of his citizens, including by chemical weapons attack, wiping out whole villages.
	We need to recognise that the spread of greater freedom, democracy and justice to the region is the best guarantee of our future security as well as the region's prosperity. That is why peace between Israel and Palestine does not inhabit a different policy domain; it is a crucial part of the whole piece. I shall meet President Abbas later today and also talk to Prime Minister Olmert. In the past 24 hours, I have had detailed discussions with President Bush and Secretary Rice. I shall emphasise again today the importance of basing the proposed national unity Government on the principles of the Quartet. I will also stress our total determination to use the new opportunity to create the chance for peace.
	I have always been a supporter of the state of Israel and I shall always remain so. However, for the sake of Israel as well as for all we want to achieve in the middle east, we need a proper, well-functioning, independent and viable state of Palestine.
	We should support all those throughout the region who tread the path of progress, from the Government of Lebanon, whose Prime Minister courageously holds firm to democracy, to those countriesthere are many nowthat are taking the first, fledgling steps to a different and more democratic governance.
	As for Iran and Syria, they should not be treated as if they were the same. There is evidence recently that Syria has realised the threat that al-Qaeda poses and is acting against it. However, its intentions towards Iraq remain ambiguous and towards Lebanon, hostile. That statements emanating from Iran are contradictory, but as the words yesterday of the head of the International Atomic Energy Agency show, its nuclear weapons ambitions appear to continue. Both countries, though very different, have a clear choice: work with international community or defy it. They can support peace in Palestine, democracy in Lebanon and the elected Government of Iraq, in which case they will find us willing to respond, or they can undermine every chance of progress, uniting with the worst and most violent elements, in which case they will become increasingly isolated politically and economically.
	No one should doubt that, whatever the debates about tactics, the strategy must be clear: to bring about enduring change in the middle east as an indispensable part of our own enduring security. The poisonous ideology that erupted after 9/11 has its roots there and is still nurtured and supported there. It has chosen Iraq as the battleground. Defeating it is essentialessential for Iraq but also for us in our country. Self-evidently, the challenge is enormous. It is the purpose of our enemies to make it so, but our purpose in the face of their threat should be to stand up to them to make it clear that, however arduous the challenge, the values that they represent will not win and those that we represent will.

David Cameron: I thank the Prime Minister for his statement. We welcome and support his announcement that 1,600 of our troops will return from Iraq by the end of this year. That news will be welcome in this House, in the country and especially to the families of those serving in Iraq over the coming months. We owe a huge debt to the professionalism, courage and dedication shown by our armed forces serving in Iraq as elsewhere and we should never forget those who lost their lives, whose families grieve for them.
	My right hon. Friend the Member for Richmond, Yorks (Mr. Hague), the shadow Foreign Secretary, and I visited Iraq in November. It was clear from our conversations with military commanders in Basra, who briefed us on Operation Sinbad, that there was a limit to what British troops could continue to achieve once that operation was completed, so it is right that they should now start to be withdrawn. But does the Prime Minister accept that that news is inevitably tempered by questions and concerns about the dire situation that persists in Iraq today, about its implications for Iraq's neighbours and the rest of the region and, above all, about the safety and security of our troops who will remain?
	In his statement today, the Prime Minister spoke about wretched and inexcusable bloodshed, and an orgy of terrorism in Baghdad. Will the Prime Minister pledge to continue to give candid assessments about the security situation in Iraq, particularly about the situation facing our forces in Basra? Anyone who has been there can see how it has deteriorated dramatically over the last three years. British troops who are there, often on their second or third tour, know that that is the case. The air station in Basra, to which many of our personnel will be withdrawn, comes under regular rocket attack, so what steps will be taken to ensure that our smaller forces based around Basra air station are able to protect themselves from encroaching militias? Will the Prime Minister confirm once again that all requests for equipment and protection will be granted?
	Looking beyond Basra to the wider situation in Iraq, we, too, want to see Iraq become a stable democracy at peace with itself and at ease with its neighbours, but we are very far from that goal today. Does the Prime Minister agree that three things are essential to bring the situation under control?
	First, the Prime Minister spoke about the rapid build-up in the strength and capabilities of the Iraqi army. Can he tell us what he believes the major gaps still are and how quickly they can be filled? Secondly, we need a more determined effort, as he said, to push Iraq's own political leaders towards an internal political settlement between Shi'a, Sunni and Kurd. Does he agree that that must mean the disarming of all militias? Thirdly, is not what is required the creation of an international contact group, including members of the Security Council and nearby states to buttress and support the Government of Iraq? Can the Prime Minister tell the House what is being done to implement those steps?
	All those were, of course, recommendations contained in the Baker-Hamilton report, which the Prime Minister set great store by at the time. But despite his claim in today's statement that the Baker-Hamilton report informed the US strategy, those steps were not all included in the different plans announced by the US Administration last month, which the Prime Minister also supported. Will he continue specifically to press for an international contact group to be set up as Baker-Hamilton suggested?
	The Prime Minister spoke of the effort to bring peace to the middle east. Again, we wholeheartedly support that. Tomorrow, like the Prime Minister, I will meet President Abbas and next week I will visit Israel and meet the Israeli Prime Minister. Our Prime Minister said that he is a strong supporter of the state of Israel; so am I.
	I note that the Prime Minister said that Syria should be treated differently from Iran, which is a change from his rhetoric about arcs of extremism, but can he tell us how he plans to engage with Syria and specifically what were the results of his envoy's visit to Damascus?
	On Iran, the Prime Minister did not specifically mention that today marks the expiry of the UN Security Council deadline for the country to suspend nuclear enrichment. Will the Prime Minister call for EU countries to join the United States in implementing additional financial sanctions to maximise the peaceful pressure that we want to see on the Iranian regime, so that it turns away from its dangerous course?
	The Prime Minister spokeimpressively, as he always doesabout the importance of spreading democracy and freedom in the middle east. He is right. There is a global terror threat; it is linked with a perverted ideology that we need to confront both at home and abroad. There are times, I agree, when it may require, as a last resort, military force to deal with it, but surely he would agree with me that we must also learn the broader lessons of the six years since 9/11; that the strategy must go beyond military force, that we need the soft power of diplomacy to accompany the hard power of military action, that we need broad-based alliances right across the region, that democracy takes time and that we should always act with moral authority. As a moral purpose always must be accompanied by moral means, surely we must recognise that, in the last six years, issues like Guantanamo and extraordinary rendition have done huge damage to our moral authority.
	On the question of learning lessons, can I ask the Prime Minister this? Many of us in the House supported the intervention in Iraq, but there have been many, many bad mistakes. Is it not essential that we learn the lessons of those mistakes?  [Interruption.] I know that the Prime Minister has up to now said that the time is not right for a full-scale inquiry led by [Interruption.]

Tony Blair: First, it is very important that we do everything we can to protect our troops, who will still face a difficult taskthere is no doubt about that at allin Basra. They will continue, incidentally, with the full combat capability that they have. What they are essentially doing is withdrawing from parts of Basra and doing the patrolling there, but the ability to get after the extremist elements, including the ones that are attacking us, remains undiminished. They will continue to do so. Of course we will ensure that they have the equipment and protection that we can give them.
	As for the Baker-Hamilton report, let me just explain that it is correct that, because of issues to do with Iran and SyriaI shall come back to them in a momentit was very much taken as if the Administration's plan published in January was a rejection of the Baker-Hamilton report, but the elements in it are the only elements that anyone looking into the issue could emphasise. They are building up the Iraqi army, building up the Iraqi governance capability and making sure that those in the region help and support in that process. Both the Baker-Hamilton report and the Administration's proposals are geared to dealing with gaps in the Iraqi army, which are essentially to do with commander control logistics, training and equipping. General Petraeus is in the process of ensuring that those gaps are dealt with.
	In respect of the Iraqi Government themselves, it is a lot to do with the actual capability of disbursing the money. For example, there is a lot of money in the Iraqi oil account that could be used for reconstruction. The fact that Deputy Prime Minister Barham Salih is now in charge of that will make a big difference. That is important.
	In relation to the contact group, there is already such a group. The issue is the extent to which Iran and Syria are going to play a constructive role in it. To be absolutely frank about it, some of the debates about what our relationship is with Iran and Syria and whether or not we are dealing with them can seem more contradictory than they really are. Ultimately, the question is this. We are perfectly prepared to deal with Iran and Syria in relation to supporting and helping the situation in Iraq, provided they are prepared to do so. The issue is whether they are prepared to do so. In respect of Syria, I think there is some sign that the Syrian Government are prepared to help. We cannot be sure of this, but there are some tentative signs.
	In respect of Iran, I have to say, it is perfectly obvious to usin this sense, we support entirely what the Americans were saying last weekthat the ordnance, much of which was used against British soldiers, has an Iranian origin. No one can be sure of the precise degree to which those in the senior levels of the Iranian Government are complicit, but it is certainly very clear that that is the origin of that weaponry.
	So the issue with Iran and Syria is that we could have any number of groups and they could come to the meetings, but what would they say when they came? Would they help or would they hinder? That is the issue that we need to explore.
	In respect of Iran's suspension of its nuclear enrichment, we will try to get a strong united European position. It is clear that, as a result of the measures that have been taken, including the financial sanctions and the sending of the troop carrier, the warship, out there, there has been a change, but we need to keep up the pressure. A very serious and dangerous situation is happening in Iran.
	On the broad fight against terrorism, there have been all sorts of debates about Guantanamo and extraordinary rendition, and I am not sure that I agree with the right hon. Gentleman[Hon. Members: What?] Incidentally, it is a matter of fact that the European report about Britain's involvement in this is simply wrong. If we were to construct a broad alliance against this terrorism, and if I had to single out one, or possibly two, issues to deal with, they would not be to do with rendition or Guantanamo or even some of the things that should never have happened, such as Abu Ghraib, which have obviously been a problem for us too. I would say that the single biggest issue that we should resolve and deal with would be the Israel-Palestine question. We also need to tackle global poverty, particularly in parts of Africa, where, if we are not careful, this same type of extremism is going to take root. If we want a broad moral purpose, those are the two clearest issues that we could address.
	We must also realise something else about these people. In my view, we will beat them when we realise that it is not our fault that they are doing it. We should not apologise [ Interruption.] No, I am sorry, we should not apologise for our values, for what we believe in or for what we do. The fact is that the values that we stand for are values that can unite Muslim, Christian and Jew, and people of different races and backgrounds, and terrorism will be better defeated if we do not apologise for our values but stand up for them.
	On the inquiry, I have nothing to add to what I said before. I totally understand that it is sensible to learn the lessons, but we will get to that point when our troops are no longer functioning in a combat situation on the ground.

Tony Blair: I thank my right hon. Friend for his commendation on the efforts that we are making. I want to see a national unity Government, and it is far easier to deal with the situation in Palestine if there is one. It is difficult, however, for us to support that Government financially, or to negotiate a peace agreement with Israel, if they are not prepared at least to say that they renounce violence or terrorism as a way of getting progress, and that they favour a two-state solution, since that is the position of the international community. I hope that we can make progress, including with the more sensible elements of Hamas. It is not a question of ignoring Hamas's mandate; the problem is how we can take the peace process forward with a Government who say that they do not even recognise the right of Israel to exist. At some point, we must find our way around that in a manner that is obedient to the Quartet principles; otherwise, we will find it very hard to make progress. My right hon. Friend will know that the political situation in Israelwhich is a democracywould make it hard for any Government there to make progress unless there was some give in relation to the recognition of Israel's right to exist. How can we negotiate two states when one side says that the other should not exist? We must try to resolve that problem.

James Arbuthnot: Does the Prime Minister agree that of all the British newspapers today,  The Sun got it most right when it said that the heroes who are coming back from Iraq deserve a heroes' welcome? I was a little surprised, however, by what the Prime Minister said in answer to my right hon. Friend the Leader of the Opposition. Does not he agree that damage has been done to the reputations both of the United States and the United Kingdom by Guantanamo Bay and extraordinary rendition? Does not he agree that there is nothing to be said by way of apology for our values, but that we need to uphold our values and act on them?

Tony Blair: I have said what I have said about Guantanamo Bay on many occasions. We should never forget that it arose out of the situation of 9/11, the problems in Afghanistan and so on. A judgment must be made, but if we are talking about how to win the battle of ideology, particularly in the Muslim world, the two issues that I have mentionedprogress on Israel-Palestine and progress on povertyare probably the major ones for those in the Muslim community here, let alone elsewhere. If we are standing up for the rule of law, I agree, of course, that we must promote that in an evenhanded and sensible way.

Ann Clwyd: I am sure thatmy right hon. Friend would agree that there aremany heroes in Iraq, including the people of Iraq themselves. This week, we had a visit from a group of 11 representatives of teachers' unions from Iraq. One of them was the wife of a man who had been executed by the regime, and another was a schools inspector who had spent four years on death row under the old regime. Whatever the leader of the Liberal Democrats saysI hope that he will go to Iraq soon, because unlike many of us, he has never been there, as far as I knowone of the teachers said:
	We are optimistic that all these things will be ended within one year, two years, three years. Then we are expecting a new life, a better life.
	Another teacher, Mohammed Saeed Hatem, said that the situation today
	was still better than it was. A bloody dictatorship has gone.
	We should not forget that.

Gavin Strang: I look forward, as we all do, to the day when the last British soldier leaves Iraq, and I heard what my right hon. Friend said in reply to the Leader of the Opposition, but will he acknowledge that, given the range of hostile elements in Iraq, there is a limit to the extent to which he can reduce the number of troops in any area without beginning to increase the risk to them? Will he assure the House that in reaching decisions in future about reducing force numbers the safety of the troops that remain deployed will be paramount?

Charles Kennedy: We all hope that today's statement from the Prime Minister marks the beginning of the end in terms of the active engagement of our armed forces. None the less, I am sure that he would want to take this opportunity to acknowledge that, for the rest of us, in this country and the world generally, it is far from the beginning of the end. The quagmire that we are almost inevitably leaving behind in Iraq, given what will now take place, will have ramifications. While he is right, or he takes the view that he is right, that no apologies should be offered, surely he should none the less take this opportunity to say that, for our country and for the Americans, it was a horrendous error at least, given what took place, never to give effect to a proper body count of the innocent Iraqi men, women and children who were lost as a result of the conflict that has taken place. That is a terrible reflection on our values as perceived in that country and the Arabic world generally, one which we will live with for a long time. When the Prime Minister did have his discussion with

Tony Blair: I think that what the hon. Gentleman is saying is right in this sense. No one wants to resolve the issue with Iran in anything other than a diplomatic way. No one is looking for confrontation with Iran, but we are faced with two unfortunate facts, as he rightly says. One is, as we can see from today, that they intend to carry on their enrichment process, which cannot be about civil nuclear power. The second is that all over the region, but obviously in Iraq, they are trying to do their utmost to undermine proper, elected Government. I think that it is possible to exert the right pressure, but he is right: we will have a far better chance of resolving this peacefully, as everyone wants, if the international community remains united and strong.

Tony Blair: I thank my hon. Friend for that and know that he would only vote according to his conscience on any of these issues. It is important to recognise the fundamental difference between Basra and Baghdad. The situation in Baghdad is simply not the same. The best guide for our own actions is the Iraqi Government. They are keen on the proposal to ensure that the Baghdad security plan is still in place and implemented. They are equally keen that the British draw down in Basra. That is because they recognise that, whereas in the one place they are fully capable of taking that control, in the other, they are not. That is a sensible way to approach that matter. I pay tribute to the allies that we have had in the south, who have down magnificent work there. This is always put in terms of British and American troops, but well over 20 other countries have been involved.

Tony Blair: It is always important that we do everything that we can to assist stability in that country. I will not go into the details of any help that we provided to that particular Prime Minister or any other Iraqi politician. If the hon. Gentleman were dealing with this matter in the way that I am, I think that he would do everything that he could to make sure that we get the necessary stability in Iraq, and sometimes it is important to work through certain politicians to do that.

Jeremy Corbyn: Does the Prime Minister realise that many people outside the House will find it very strange that in his statement he made no reference to the hundreds of thousands of Iraqis who have died in the past four years, or to the effect of depleted uranium usage and cancer rates in Iraq, or to the remaining cluster bombs? Does he not also think that the current attitude towards Iran and the threats being made towards it are leading us into another disaster like that which we are apparently about to come out of in Iraq?

Tony Blair: First, let me tell the hon. Gentleman that my experience over the past few years is that I am singularly incapable of spinning the media one way or another on issues [Interruption.]particularly on this issue, on which it is incredibly difficult to get any balanced coverage at all. However, what he says is absolutely right. The reason why we are able to draw down is because the conditions have been met. It would be absolutely disastrouswe are not doing this in any shape or formto say that future drawdowns are unconditional. Everything is conditions-basedbased on progress and the capability of the Iraqi forces.

Tony Blair: I do not think that poverty per se is the reason for that theocratic fundamentalism; I agree with the hon. Gentleman on that. However, I do think that improved economic development plays a part. That is particularly the case in the African context where there are very worrying developments of this same type of extremism getting a foothold in conflicts. In general terms, the more prosperous and democratic people are, the less inclined they are to be drawn to any form of fundamentalism, political or theocratic.
	Let me say what I think is the interesting thing about Iraq and Afghanistan. Where the people were given the chance to vote, they voted not to have fundamentalism. They voted for a broad-based non-sectarian Government. The key question is whether the extremistssome of whom are attached to theocratic fundamentalist movementscan push them into sectarianism, even though their first desire was not to go towards that at all. We need to deal with both of the issues referred to, but I believe that the more economic development there is in the region, the better it will be.

Brian Iddon: I beg to move,
	That leave be given to bring in a Bill to confer further powers on local authorities for the regulation of street trading by pedlars; and for connected purposes.
	The current provisions on street trading, which is different from peddling, can be found in schedule 4 and section 2 of the Local Government (Miscellaneous Provisions) Act 1982. They allow local authorities to designate streets for the purpose of street trading; however, the regulation of pedlars is exempted from those provisions. The main legislation on the regulation of pedlars is the Pedlars Act 1871. In my opinion, 19th-century legislation can no longer cope with changes in the way that goods are marketed and sold today. Our consumers and business people deserve up-to-date legislation that can ensure their protection from rogue traders.
	The 1871 Act defines a pedlar as
	a person who, without any horse or other beast, travels and trades on foot from town to town carrying to sell or exposing for sale any goods, wares or merchandise or procuring orders for the same, or selling or offering for sale his skill and handicraft.
	The Act specifically does not include the now common practice of a pedlar standing in one place for an extended period to sell their goods or services. Over the last decade, local authorities have reported increasing problems with pedlars. Registered pedlars are now selling goods in our town and city centres from bags, trolleys or stalls, often remaining in fixed positions for long periodsa practice not covered by the Act. An increasing number of persons who are neither registered as pedlars nor licensed as street traders are behaving similarly.
	Under the provisions of the 1871 Act, the police are responsible for issuing pedlars' certificates. Once issued, they allow pedlars to operate all over the country without the need to re-register. Although local authorities have prosecuted for breaches of the pedlar regulations, it is clear that the current enforcement provisions are ineffective.
	A survey undertaken jointly in 2005 by the National Association of British Market Authorities, the National Market Traders Federation and the Association of Town Centre Management revealed widespread abuses of pedlars' certificates across the land. The current system allows unlawful traders, under the guise of possessing a pedlar's certificate, to sell goods virtually unregulated on the street. Evidence suggests that some pedlars view the fines imposed by the courts as merely a business expense. Their activities are damaging local markets and the surrounding small businesses, which are subject to greater regulation and overheads such as business rates and rents.
	The situation in our towns and cities is becoming so bad that a number of local authorities have provided themselves with local legislation to ameliorate the problem. That is both time-consuming and extremely costly. Newcastle upon Tyne's recent course of legislative action cost it almost 200,000. So far, Newcastle upon Tyne, Maidstone, Leicester and Liverpool have taken out local legislation, and in the current parliamentary Session, Manchester, Birmingham, Derby, Sheffield, Rotherham, Bradford and Bournemouth are promoting their own local legislation. Such cross-country activity demonstrates the widespread scale of the problem, but it is creating a patchwork of legislation.
	Where local legislation has been pursued, benefits to the local economy and community have quickly been seen. For example, enforcement of local legislation in Newcastle upon Tyne has resulted in the removal of pedlars and unlawful street traders from the city centre. That, in turn, has improved the environment for legitimate street traders. The local legislation implemented in some parts of the country has taken as a model the provisions in the London Local Authorities Act 2004. My Bill will allow local authorities outside London to benefit from the powers that authorities in London can already exercise. Its provisions will allow the immediate seizure of goods, which, of course, means the swift cessation of trading. However, my Bill preserves the right of pedlars to operate, as they were originally intended to, outside town and city centres. Although there is compelling evidence for the success of local authority initiatives, there is widespread concern that if a national approach is not taken, pedlars and unlawful traders will simply move from one town centre to another. A nationwide approach is needed to ensure a cohesive and co-ordinated approach to peddling.
	My Bill is supported in Parliament by the all-party parliamentary group on the markets industry, of which I am a vice-chairman. It is also supported by the National Association of British Market Authorities, the National Market Traders Federation, the Association of Town Centre Management and the Association of Chief Police Officers. ACPO supports transferring the regulation of pedlars from police authorities to local authorities, and it has also expressed concern about the relationship between some pedlars and unlawful street traders and the sale of counterfeited goods. The Local Government Association and the Institute of Licensing have also expressed their support for this Bill. They report that many of their members have contacted them in connection with the problem of unlawful pedlars and illegal street traders.
	Since announcing the presentation of this Bill, I have received tremendous support from right hon. and hon. Members of all parties and from local authorities throughout the land, for which I express my thanks. My Bill is surely not contentious, in that it seeks to make nationwide powers that are available to only a handful of local authorities. It will prevent a piecemeal approach to legislation, which is driving unlawful traders from one town centre to others. The crucial power of seizure of an unlawful trader's goods will enable local authorities to act swiftly in preventing unlawful trading, and consumers will be protected from purchasing counterfeited, stolen or sub-standard items on the streets of our towns and cities.
	I stress again that my Bill does not outlaw peddling; rather, it clarifies its definition. Legitimate pedlars will still be able to sell their goods, as defined in the 1871 Act. I recommend 21st-century legislation for 21st-century traders, and advise the House to equip our local authorities with powers to enable them to protect our streets, our consumers and our local markets and small businesses from rogue traders. I therefore commend the Bill to the House.

Christopher Chope: It is most unfortunate that the hon. Member for Bolton, South-East (Dr. Iddon) has smeared pedlars as rogue traders, because they are two different groups of people. I wish to put in a plea for lawful pedlars. They are hardworking, entrepreneurial, market-driven, self-employed and law-abiding traders who provide services much appreciated by the public at competitive prices. It is not my intention to divide the House as the hon. Gentleman has every right to introduce a Bill, but it would be wrong for him to think that it would go unchallenged by those of us who believe in choice, competition and free enterprise.
	Pedlars are already regulated. A pedlar's certificate is renewable annually. If a pedlar is convicted, the certificate is revoked and will not be renewed. A pedlar cannot obtain a certificate to peddle if they are a bad or undesirable character. Every application made for a pedlar's certificate is subject to a police check to ensure that the person is of good character. The law clearly defines the difference between legal peddling and illegal street trading. The High Court has ruled that pedlars may stay in one place for up to 15 minutes, but not longer. The example given by the hon. Gentleman of a person carrying on street trading in a location without a certificate for a period longer than 15 minutes is already unlawful. Why damn all pedlars because some people break the law? Those people are illegal street traders already.
	Under section 15 of the Pedlars Act 1871, a pedlar must produce his certificate on request to a policeman, a justice of the peace or any member of the public who so requests. It is a fallacy that the general public are against pedlars. If they were, pedlars would go out of business. Let us have some trust in the public to use their common sense and judgment in deciding whether or not to buy from pedlars. Contrary to what the hon. Gentleman implied, customers have protection in relation to the goods bought from pedlars. Pedlars have a duty to exchange or give a refund on any goods with which a customer is dissatisfied. The police also have powers of confiscation if they believe that goods are illegal, as do trading standards officers. We should put the issue in perspective.
	Many people will be amazed that the hon. Gentleman and his supporters seem to be more concerned about removing the freedom of pedlars to sell helium balloons to children than about stamping out the sale of illegal drugs to children in our town centres, which is a far more serious issue of concern to our constituents.
	 Question put, pursuant to Standing Order No. 23 (Motions for leave to bring Bills and nomination of Select Committees at commencement of public business), and agreed to.
	Bill ordered to be brought in by Dr. Brian Iddon, Mr. David Amess, Jim Dobbin, Mark Hunter, Mr. Eric Illsley, Alison Seabeck, Anne Snelgrove, Mr. Phil Willis and Sir Nicholas Winterton.

Opposition Day
	  
	[6th allotted day]

Andrew Lansley: I beg to move,
	That this House recognises the need to develop and improve acute hospital services; is concerned that current reconfiguration proposals are being dictated by financial and staffing pressures; believes that the Government cannot call for change whilst failing to put in place the commissioning and tariff structures necessary to support, for example, maternity services, acute stroke care, cardiac care and vascular surgery; regrets the Government's lack of support for models of service configuration which would secure high standards whilst maintaining access; calls on Ministers to bring forward proposals to mitigate the effects of the European Working Time Directive on hospital services; insists that reconfigurations should be based on safety, quality of care, accessibility and choice; is deeply concerned that NHS staff, public and patient voices are not given appropriate weight in the decision making process; and calls for a stronger local democratic voice that will contribute to public confidence in the planning of acute NHS services.
	It is just over a year since the Government's White Paper. Far from being the best year ever for the national health service, it has been a year of deficits and financial and staffing pressures. We learned yesterday that the gross deficits across the NHS will be continued from last year into this financial year, that the number of redundancies continues to rise andas a consequence of the White Paperthat hospitals across the country are threatened with cuts and closures. There are widespread concerns and anxieties, to put it mildly, about the implications.
	The Secretary of State mandated that state of affairs by saying in the White Paper that resources would be moved into the community. In practice, the implementation of those words means that hospital budgets are being constrained, so cuts and closures are happening in the hospitals, but the infrastructure has not been created, or resources supplied, for patients to be looked after closer to home. I was interested to see that that point came across in the results of a recent consultation in Warwickshire. People said, Don't cut back our hospital services, because we cannot yet see the resources being put into the community.
	The process that the Secretary of State set in train a year ago has led to demonstrations in west Cornwall, Banbury, Chichester, Haywards Heath, Salford [ Interruption. ] Yes, even in Salford. The Labour party chairman was there with her megaphone and placard. I must not leave out Worthing. Those demonstrations were against the consequences of the Government's policy and are unprecedented in my experience in their scale and extent, especially over such a short period of time.

Andrew Lansley: I am grateful to my hon. Friend and I should not have left out Surrey. In fact, I should not have left out lots of places, but I did [ Interruption. ] Yes, I should not have left out Hertfordshire or Shropshire. I am grateful to my hon. Friends. I could have mentioned Worcestershire, home to the Labour Chief Whip, or Lanarkshire, home to the Home Secretary.
	My hon. Friend the Member for Mole Valley(Sir Paul Beresford) makes an important point. I do not know whether he knows it, but one of the consequences of the way in which the reconfigurations are being pushed by NHS bureaucracies is that referrals are being manipulated through the choose and book system. I was talking to GPs in Yorkshire a few weeks ago, and one told me, I sit there with my patient and we look at the waiting times for the hospitals that are available to us. The patient chose a hospital in Leeds, where she could be seen quickly. We went through the choose and book system, but the primary care trust, which has an enormous deficit, took hold of the referral. The PCT, in effect, said to the patient, Yes, you might like to go to Leeds, and Leeds could treat you in two or three weeks' time, but you will not be seen until April because that is when the new financial year starts. So, what is the point of choose and book?

Andrew Lansley: I am glad that my hon. Friend made that point. In our motion, we say that we want to reassert the need for the voices of local peoplenot just the public, but professional local voicesto be heard in questions about reconfiguration. He is rightit might not have been something that everybody in Hertfordshire was entirely happy about, but they signed up, by means of a long investing in health process, to the idea that it was necessary for them to have specialised services provided in a new hospital. That happened before the general election, and the hospital was going to be in Hatfield. My hon. Friend, happily, secured his seat at the last general election. However, because the increase in deficitsthat has occurred since 2005if the Government say that the issue is not about deficits, this gives the lie to that propositionthat large new hospital has gone completely out of the window. Every time Ministers say, The evidence tells us that you've got to have more specialised services that are in a larger, new hospital, just think of Hertfordshire, where it is obvious that deficits are destroying even the Government's own proposition.

Howard Stoate: I grateful to the hon. Gentleman for giving way, particularly after his warms words about me. I think that I am right in saying that I am the only person present who uses the choose and book system. I use it regularly and the only thing that I find wrong with it is that there are not yet enough specialities for which we can use choose and book. The faster it expands and becomes universal for all referrals, the better. I can now sit down with one of my patients, go through every available hospital in my district and tell them precisely how long each waiting list is for each consultant. It cannot get much better. It needs to improve, but the basic system is very effective.

Andrew Lansley: I am sorry, but the hon. Gentleman is completely missing the point. A GP in Yorkshire who used choose and book said that he made a decision on the basis of the available waiting times at different hospitals. The primary care trust then took that decision away and negated it by saying that people had to wait 17 weeks anyway. I do not see what point the hon. Gentleman is making. We are not against direct booking or online booking. He ought to take the matter up with his colleagues on the Front Bench, whose job it was to deliver choose and book on time and who have not done so. Norman Warner pushed off. He was supposed to deliver choose and book, but he has gone already. He has got other fish to fry and perhaps we will talk about them later.

Daniel Kawczynski: Sorry. With regards to reconfiguration, does my hon. Friend agree that areas such as Shropshirerural countiesare far more affected because of the huge distances that constituents have to travel? Will he press that point strongly to the Secretary of State?

Andrew Lansley: I am grateful to my hon. Friend because he takes me to where I wanted to go next.
	There should be no argument about the desirability of moving acute hospital services forward and of adapting and improving. In my experience, all the campaigns that we have been talking about across the country are not saying that nothing must change

Andrew Lansley: Yes, I agree with the hon. Gentleman. He might recall our debate on maternity services at the beginning of January, when that point was illustrated well. When I visited Brecon Memorial hospitalit is not in his constituency, but it is close byI could see that it provided an excellent service. The hospital makes an enormous difference to the mothers whom give birth there and also relieves what would otherwise be serious pressures on other hospitals.
	It is important to say that we accept the drivers of change. Let me quote the Secretary of State:
	Modern medicine means also that we can treat more patients with fewer beds. Many more services can be provided outside hospital.[ Official Report, 16 February 1993; Vol. 219, c. 133.]

Andrew Lansley: The Secretary of State is agreeing not with herself, but with what the then Conservative Secretary of State said on 16 February 1993. The argument has not changed; the point is, what have the Government been doing about it? They have not been doing anything.
	Let us have a look at what the Government have been saying. Their amendment to the motion focuses on some of the things about which they have started to talk. Suddenly, in December 2006, the clinical directors at the Department were invited to pop up and saywhy there was a case for the reconfiguration ofclinical services. We had a maternity services debate on 10 January and, lo and behold, by 6 February the clinical director for children's and maternity services popped up with a reportwe will come to that in a minute.
	As was illustrated by the clinical directors' reports on accident and emergency and cardiovascular services, the question of A and E is often at the heart of this. A central point that has been argued for a long time is that full access in A and E to every specialised form of treatment cannot be maintained. Conservative Membersand certainly Conservative Front Benchersdo not argue that every A and E department in the country should be able to treat every patient. We have never believed that. For example, when Richard Hammond had his accident, he went to not the local hospital, but to Leeds general infirmaryquite rightly so, because it was able to provide excellent neurological care. The same will be true in every part of the country, but the question is how far that specialisation should go.
	The Government's documents focus on such issues as heart attacks and stroke. With regard to heart attacks, they talk especially about primary angioplastythe Government cite that in their amendmentwhich is a mechanism whereby rather than giving thrombolysis in all cases, even if this takes a little more time, a balloon is put in a patient's artery to re-engage the blood flow, after which a stent is put in to maintain the flow.
	The procedure is not new. We did not suddenly discover it at the end of 2006. When Roger Boyle, the clinical director, produced his document, I asked him on what clinical evidence he based it. I was referred to an article of January 2003, which itself said:
	In 1995 and in 1997, systematic reviews of this topic were published, with the later analysis of 2,606 patients, showing improved short-term clinical outcomes ... with primary PTCA
	the primary angioplasty interventioncompared with thrombolytic therapy.
	So, from 1995, 1997 and 2003, there has been consistent information about the procedure.
	I am not saying that the Government's study discovered that in 2006. Towards the end of 2004, they began pilot studies. The hon. Member for Pudsey talked about Leeds. I visited Leeds general infirmary in March 2005, when it was involved in the pilot studies on primary angioplasty. However, I remember a conversation with the clinical directorif he puts himself in the frame of being the Government's mouthpiece, he must take thiswhen I hosted a reception here on saving minutes, saving lives to celebrate success on call-to-needle times for thrombolytic therapy. I asked him what plans he was putting in place to move beyond that procedure to primary angioplasty, and he said, Well, for the moment, we're going to concentrate on the target and we'll worry about that later.
	I will not take lessons from Government Ministers about us standing in the way of progress when the situation regarding the procedure has been clear for a long time. A million cardiological interventions involving primary angioplasty already take place in Americait is increasingly routine. I remember a cardiologist telling me in early 2004 that although the procedure was routine in the Czech Republic, it was virtually not happening at all in this country. The one place in this country where it is increasingly routine is London. There are 32 accident and emergency departments in London, nine of which offer primary angioplasty. Patients with myocardial infarction are going to those nine departments. Why are they going there? It is not because the Government have published anythingthey are still spending their money and time on pilot studies and it will take a while before they publish the evaluationbut because the London ambulance service has taken the initiative. Frankly, if the Government got out of the way and people in the national health service were given greater freedom to deliver the services that they know are right, we would make more progress, more quickly.

Andrew Lansley: Is the hon. Gentleman? Oh well [Interruption.] If the hon. Member for Stockton, North (Frank Cook) had angioplasty, that is one thing, but if he had primary angioplasty, it is another. If he had an acute MI [ Interruption. ] It helps to have a doctor, although I prefer my doctor to the one from Dartford.

David Wilshire: Does my hon. Friend agree that the reports suggesting that change is for the better would be more convincing if they were not being used as a smokescreen? In March 2005, Surrey Members were told that a hospital andits A and E department had to be closed to save120 million. Nine months later, a report was commissioned and it is now being waved about as an alternative justification for something that we were told was being done to save that money. No wonder we do not believe reports if they are used as smokescreens.

Andrew Lansley: My hon. Friend is absolutely right.St. Peter's and Ashford hospitals, along with others in Surrey, are wondering where on earth the evidence is for the reconfiguration that will be forced upon them. They know that it will be forced upon them because the Secretary of State went to a meeting with the chairman and chief executives of the then strategic health authority in which she told them that a hospital needed to shut and that she would be prepared to push that through. She can always intervene to deny that if it is not true.

Andrew Lansley: The Minister says that, and she is responsible for the issue, but as she will know, because she came to see the all-party group, we want action and we want it now. We are not standing in the way of it, so I will not take any lectures from her, or from the national clinical director. They produce documents that say that it is important that we adopt those measures, but it is they who have been standing in the way of those changes.
	On accident and emergency services, I accept that there are cases in which a blue-light ambulance is called, and it does not go to the nearest hospital, and of course we have to accept the argument for that. However, as a consequence, across the country, primary care trusts and strategic health authorities are saying, We've got to downgrade units. I went to Chase Farm hospital accident and emergency unit, and people there were saying, We want to become a minor injuries unit. Frankly, the choice is not between having a full-service accident and emergency department and having a minor injuries unit. As George Alberti makes clear in his document, it is perfectly valid for us to retain accident and emergency departments.
	If we add up all the myocardial infarctions, strokes, major head injuries, aneurisms and demands for vascular surgery, they still account for only about 300,000 out of 13 million attendances at type 1 accident and emergency departments. We cannot have a situation in which the NHS, because of financial deficits and the impact of the working time directive, shut accident and emergency departments across the country, so that 97 per cent. of the people visiting those departments lose access to them, on the excuse that 3 per cent. of patients need to be blue-lighted to a more specialised centre.

David Burrowes: I am grateful to my hon. Friend for referring to Chase Farm, and I share his concern about its move towards having a minor injuries unit; that is simply one option among many concerning accident emergency. Does he welcome the fact that Sir George Alberti is now to report on Chase Farm specifically, and the options open to it? Will he make the point that Chase Farm has a wide catchment area, and we should not move quickly to downgrade, simply in the interests of saving money?

Andrew Lansley: I entirely agree, and I hope that George Alberti, for whom I have a lot of respect, will come to the right conclusions in his report. I will not go on about maternity services in detail, because our debate on 10 January covered that subject, or most of it, but since 10 January, the Government have produced a document from the national clinical director for children, young people and maternity services. Fascinatingly, what is does not tell us is far more significant than what it does. It does not tell us anything about whether there are enough midwives to provide maternity services, and it does not tell us what might be regarded as safe transfer times between a midwife-led unit and a consultant-led unit. It does not tell us how swiftly, and under what circumstances, mothers should be able to have an emergency caesarean section.
	In fact, at one point the report commends the fact that, in Huddersfield, a unit shut down because it could not maintain eight consultants and at least 2,500 births a year, but two pages later, it says:
	There is no optimum number of births to make a unit sustainable.
	There is no evidence in that report, published by the Department, that informs thinking on the delivery or configuration of maternity services across the country. It does not help at all. Indeed, I am afraid that across the country, campaigners are having to put together the arguments themselves, because the arguments are not presented in the work done by the Government.
	Who is standing in the way of change? Let us have a look. The Labour party chairman, in Salford, does not agree with the Government's policy. The Labour Chief Whip, who stood outside the Alexandra hospital in Redditch, does not agree with the Government's policy. The Home Secretary does not agree with the Government's policy, because of the closure of his local accident and emergency department up in Lanarkshire. I could go on; the list even extends to the Prime Minister. Back in September 2004, there were proposals for the reconfiguration of acute hospital services in north Teesside, and the Prime Minister, with the then-Secretary of State for Health, now the Home Secretary, came to Hartlepool. As it happens, it was in the middle of a by-election, but of course I would not suggest for a minute that, in the heat of a by-election, the Prime Minister would say something that he did not believe, and that he was not prepared to deliver on subsequently. He arrived and said:
	There is no question of the hospital closing or being run down.
	Subsequently, it was proposed that precisely that should happen.
	The decision taken in that case may be right, or it may be wrong; it is not really for me to say, but the independent reconfiguration panel has become involved. Curiously, there have been 20 referrals from overview and scrutiny committees to the Secretary of State, and five of those, including three from local authorities in north Teesside, have been sent to the IRP. There is one single characteristic shared by those five referrals: they all related to places where Labour Members of Parliament were arguing with each other. They concerned north Teesside, Calderdale and Huddersfield, and, more recently, Greater Manchester. If Labour MPs are arguing with each other, and the Secretary of State does not want to have to decide between them, the case goes to the independent reconfiguration panel. In places where Liberal Democrat or Conservative Members of Parliament are involved, she will rubber-stamp the decision. Bang! There we go; the decision is made, and the debate is shut down immediately. She does not care.
	At one point, the Secretary of State received proposals that the NHS hospital rebuild should be in Sutton, but she not only did not accept what the local NHS was telling her, but said that the rebuild had to be at St. Helier hospital, whichlo and beholdwas in a Labour constituency, but she subsequently had to completely abandon her proposal.  [Interruption.] Well, it serves a Labour constituency. We know perfectly well what that was all about. She subsequently had to abandon her intentions in the face of judicial review. Credit must go to my hon. Friend the Member for Reigate (Mr. Blunt) and other hon. Friends for seeing off the Secretary of State's desire to gerrymander NHS services for political gain.

Andrew Lansley: I must conclude, because many Labour Members wish to make their own contribution.
	The point of the motion is straightforward. I do not accept the proposition that we stand in the way of change. We believe in change to improve the national health service, whether it is primary angioplasty services, stroke services or reconfiguration to make sure that we deliver maternity services more effectively. We have made that clear, both today and in our previous debate. We will not allow the Labour Government to pretend that clinical considerations drive changes in the NHS that are not in patients' interests. The proposed changes are not substantiated by clinical evidence, and there is no basis for them. The Government have not introduced a national stroke strategy or made an evaluation of primary angioplasty pilots. They have not conducted a review of walk-in centres. The Secretary of State said that it would be published in the new year, but we have not seen it. It has all gone out the window. The Government argue for change, but they do not provide the evidence for it.
	We know what it is going on, as the Government published the figures yesterday. Deficits of some 1.3 billion are littered across the national health service, and one third of trusts are potentially in deficit. The Government, however, are determined to drive down activity in the hospital sector to try to rescue the Secretary of State from the consequences of financial deficit. Astonishingly, the right hon. Lady now argues that fewer beds are a sign of success. It is Yes, Minister politics, and in the next episode it will be suggested that if none of the patients turns up at hospital the NHS will work brilliantly. Fantastic! The Secretary of State has said that we are just over halfway through the NHS plan, but how many of her colleagues have re-read that document, which was published in 2000? I suggest that they look at it, because it is very interesting. It does not say anything about payment by results, practice-based commissioning or foundation trusts. It says, however, that the Government will implement a national beds inquiry and increase the number of beds by 7,000. Bed occupancy rates are so high that the number of cases of Clostridium difficile has risen from 17,000 six years ago to 45,000 in the past year, so we will not accept their lectures on the subject. Fewer beds will be acceptable when occupancy rates in hospital are such that patients can be treated properly and nurses have time to clean a bed before it is taken by the next patient.

Graham Stuart: Thanks to the advance of modern medicine and improvements in public health, the number of beds has generally declined over the years, but that will not continue for ever. Our bed use is similar to that of the United States, where it is among the most efficient in the world. In the East Riding of Yorkshire alone, every year, there is a net increase of 500 in the number of people who are over 85. When elderly people are ill, they need a hospital bed. They need time to recuperate, and they need community hospitals as well as decent acute hospitals. The Government believe that that downward curve can go on for ever, but it cannot.

Andrew Lansley: Absolutely. I agree with my hon. Friend. We have made that point, and I know that his constituents subscribe to the campaign that he is fighting on community hospitals. Indeed, I recently read a letter from Professors Flint and English from Beverley in east Yorkshire making exactly the same point about the necessity of maintaining access to services closer to home. That is what the Secretary of State told us that she wanted. It is what my hon. Friend wants, and it is what we are arguing for but,as a consequence of Government policy, we couldlose it.
	In the motion, we are seeking to reassert the right and need for the NHS locally to make decisions in the light of views expressed by professionals, patients and the public. Decisions should be based on clinical evidence, rather than being driven by deficits and financial pressures. We want an NHS in which we do not stand in the way of change. That change, however, must be managed well.  [ Interruption. ] The Secretary of State scoffs, and says that change must be managed by the Department of Health, but before she goes down that track, she must accept that 96 per cent. of senior civil servants in the Department did not believe that departmental change was managed well. Some 81 per cent. disagreed or strongly disagreed with the proposition that change was managed well. There is no belief in the Department itself that it manages change well and there is no confidence in the Department's leadership. I do not blame the civil servants, as it is Ministers who decide and lead. This Minister has failed to lead her Department or the national health service. Doctors do not have any confidence in her, and we know from Monday's edition of  The Times that they have far more confidence in my right hon. Friend the Member for Witney (Mr. Cameron) than in the present Government or prospective Government under the leadership of the Chancellor of the Exchequer. They believe in what we are saying for the national health service, and they know that we are fighting for it, so I commend the motion to the House.

Patricia Hewitt: No, I should like to make some progress first.
	The hon. Member for South Cambridgeshire complained about reconfigurations and changes to the health service across the country, before complaining that they have not taken place fast enough. Of course, health services are changing fastand they will continue to do sobecause medicine and, people's needs are changing. The NHS has to keep up with those changes, as it has always done. The hon. Gentleman referred to the White Paper entitled Our health, our care, our say that we published last year after the biggest ever public engagement on health policy that any Government have undertaken. The White Paper was warmly welcomed by professionals, staff and trade unions, as well as by voluntary organisations across the country.

Patricia Hewitt: The role of Homerton hospital and others like itHomerton hospital is a superb hospital taking full advantage of its relatively new foundation trust statusis to do the things that can be done only in an acute hospital, working with GPs, health centres and other parts of the local NHS to ensure that wherever possible, care is delivered to people closer to their own homes because that is more convenient for patients, better for them, and better value for the local NHS, and then to focus in the acute hospitals on the particularly complex cases, the specialist care and the in-patient surgery that can be done only in a hospital like Homerton. That is the future policy of such hospitals, and I know very well from my own visits to Homerton that staff there not only understand that, but welcome it and embrace it because it will improve care in one of the most disadvantaged parts of London, as my hon. Friend well knows.

Patricia Hewitt: No proposals have yet been made either in West Sussex or in Surrey. Opposition Members should stop telling people that hospitals are to close when there is no intention to do so and no proposal has even been made.

Martin Linton: Does my right hon. Friend agree that many of the closures that one hears about are not closures at all? Wandsworth council is running a scare campaign against what it calls a closure, when in fact the proposal is to move out-patient services half a mile into larger premises in a brand new NHS building that has not yet been opened, yet at the same time Conservative Wandsworth council really is closing two libraries, a museum and an art gallery.

Patricia Hewitt: I certainly can. Given the state of the NHS that we inherited from the Conservatives 10 years ago, we desperately needed more capacityboth beds and staffwhich we delivered, thanks to the record investment that we made and the Conservatives opposed. We are now seeing a reduction in the number of acute beds as a direct result of modern medicine and more day-case surgery in particular, and a continuing increase in the number of critical-care and intermediate-care beds where those are needed.
	The Conservatives constantly accuse us of closing hospitals. That, too, is absolute rubbish. More than150 acute hospitals have been refurbished or rebuilt, or are on the way. Hospitals are working differently, as was pointed out by my hon. Friend the Member for Hackney, South and Shoreditch (Meg Hillier). They are doing what only hospitals can do. Health services are provided as close to home as possible, but are provided in hospital where necessary.
	Waiting lists are at their lowest ever in the NHS. Almost no patient waits for more than six months for operations such as hip replacements for which people used to wait over a year, sometimes up to two years, under the Conservatives. But now the NHS is doing even more. Earlier this week my right hon. Friend the Prime Minister announced that 13 hospital trusts expected to be able to guarantee most of their patients a maximum wait of just 18 weeks from GP referral to hospital operationfar less, in the majority of casesand to achieve that by the end of the year, a year earlier than the goal that we set. That is an enormous achievement, and I congratulate all the staff involved. However, as the medical director at King's College hospital told my right hon. Friend and me on Monday, the NHS cannot get rid of waiting lists by doing things in the same old way; they can do that only by transforming the way in which hospitals, local GPs and other services work.
	Bolton, for instance, has provided a clinical assessment and treatment centre where patients who would formerly have waited to see the orthopaedic consultant at a hospital are now referred to a community team. An orthopaedic consultant in the community, one of the first consultant physiotherapists in the country and other staff are all working together, treating patients who do not need surgery. Those patientsabout 70 per cent. of the totalare given physiotherapy, or other treatments that they may need, much faster; meanwhile, hospital consultants can concentrate on the patients with the most serious problems, and spend more time on surgery. As a result, waiting times both for patients who need physiotherapy or other community treatment and for those who need in-patient care have been cut from months to weeks. That too is an enormous achievement. It means that the right care is being given to patients by the right professionals in the right place. That is the kind of reconfiguration that we need throughout the country.

Patricia Hewitt: May I advise the hon. Gentleman to read Roger Boyle's report and indeed to talk to his hon. Friend the Member for South Cambridgeshire? The hon. Member for South Cambridgeshire rightly referred to Australia, which has much better survival rates for stroke and, I believe, heart attack, and better availability of primary angioplasty services. The distances that people have to travel in that country are a great deal larger than anything that will be encountered in most parts of our country. In north Tees and other parts of the north-east, for instance, patients who have suffered a heart attack or stroke and need the specialist services of the excellent James Cook university hospital in south Tees are in many cases brought there by air ambulance, because it would take too long for them to travel by road ambulance to get the life-saving treatment that they need. That is another reason why such decisions need to be made locally in order that local ambulance services and hospital services can be organised in the best way.

Patricia Hewitt: I am not aware of the exchange that the hon. Gentleman mentions. It is clear that the NHS is already building up more specialist centresfor cardiac patients, burns patients and so onthat will give people the best possible care with the best possible chance of saving their lives. I think that the hon. Gentleman supports thatI certainly hope soand I hope that he will persuade other Conservative Members to do so.
	The hon. Member for South Cambridgeshire mentioned the tariff for stroke services, which is extremely important. Professor Boyle has been working on that with clinical colleagues in the tariff team, and as a result we have already announced that we are changing the tariff for 2007-08. We will continue to make improvements to it. We are sometimes accused of introducing payment by results too quickly and sometimes of introducing it too slowly; the reality is that we are doing it faster than in almost any other country because we are determined to get the benefits from that.
	Professor Sir Ara Darzi, one of our country's leading surgeons, who is conducting a review of health care across London, has summed up the changes that are taking place very simply:
	health services as close to people's homes as possible...in hospital where necessary.
	That is how the NHS will help more people to stay as healthy and independent as possible, how it will give patients the best and fastest care possible, and how it will deliver the best possible value for the public's investment.
	Of course change is difficult, particularly for the staff affected, and of course changes can be unpopular, particularly when they involve a much loved local hospital. However, if we knew that by changing the way in which services are organised the NHS can improve more people's lives and save more people's lives, we would be betraying patients and betraying the NHS if we refused to make those changes just because they involve difficult local decisions. I do not expect Conservative Members to face up to that. No doubt they will go on saying different things to different people, go on saying that they support NHS staff while attacking higher pay and decent pensions, and go on saying that they support changeindeed, that they want independence for the NHSyet going out on to the streets to oppose every local change that is proposed. They are even organising demonstrations to save hospitals that nobody proposes to change.

Norman Lamb: The Secretary of State shakes her head, but there is no doubt that they are. That demonstrates how potent the issue is and what a mess Government policy is in.
	The first point to make is that political argument over reconfiguration of acute hospital services is not new. That was demonstrated by the hon. Member for Pudsey (Mr. Truswell), who mentioned six hospitals that had closed under a previous Conservative Government. It has been going on for as long as the NHS has been in existence. However, it is now more controversial than ever before, for reasons that I shall explain later.
	To start with, the NHS inherited a patchwork of hospitals from the previous local authority provision, and since then there have been various landmark changes. In 1962, when Enoch Powell was a Health Minister, he published his Hospital Plan for England and Wales. He described the role of the district general hospital as having 600 to 800 beds serving a population of 100,000 to 150,000 people, with some specialties being dealt with in larger teaching hospitals. In 1980, we had another landmark Department of Health paper that argued the case for more accessible local hospitals. Throughout that period, under Governments of both parties, a considerable number of smaller, vulnerable hospitals have closed down despite protests from the public.
	Interestingly, since this Government came to power in 1997, reconfiguration of services has not been a priority until very recently. The NHS plan in 2000 concentrated on the case for building more hospitals, not closing them. There was a promise of 100 new hospitals by 2010, many financed using the private finance initiative. That produces a straitjacket of accommodation that is particularly unsuited to adaptation to take account of changing health needs and priorities. I looked at the 2005 Labour manifesto to see what that said about reconfiguration of hospital services, but there was nothing there. Does that mean that in 2005 the Government had not thought about reconfiguration or that they had thought about it and kept it from the public debate? Nothing was said about it in the general election campaign, yet it has become a significant part of Government policy since then.

Norman Lamb: The hon. Gentleman makes a good point. The figures that were published yesterday show that the top-slicing has plunged many more organisations into deficit and genuine financial difficulty, potentially affecting patient care.
	Not only politicians make such points about the impact of deficits on decision making. In a briefing in November, the King's Fund wrote:
	Financial pressures within the NHS are being felt at both local and national levels, adding urgency to decisions about which services should be provided, where, how and by whom. At a local level, the presence of financial deficits in individual NHS organisations is forcing trusts to consider which services they can afford to provide and which must be cut.
	Those decisions are determined or significantly influenced by deficits. The briefing continues:
	At a national level, the anticipated end to large increases in funding for the NHS after 2008 is prompting the Department of Health to focus on how the delivery of health services across the system as a whole can be made more cost-effective.
	An impeccable independent source acknowledges that deficits and an end to the growth in funding are central in the reconfiguration debate.
	Before Christmas, the Select Committee on Health made the link between deficits and reconfigurations in its report on deficits. It referred to evidence from the acute trust in Worcestershire. The trust stated that service reconfiguration was essential, but that it would not be enough. I quote:
	the Trust Board has recognised that it will not be able to make the final steps to achieve recurrent financial balance without even more radical action. This will involve a comprehensive review of services across the three sites and serious questions about their sustainability.
	That is reconfiguration driven by financial crisis.
	I said earlier that I had spoken to a consultant in the East of England region, who said that his colleagues had raised concerns specifically with the strategic health authority about the dire financial situation in that region. He raised the related concern that that was driving the pressure to reconfigure. Let us be absolutely clear: reconfiguration decisions tainted by trusts suffering massive deficits cannot be justified.
	The second flaw in the Government's approach is the extent to which the whole process is being centrally drivena point made in a number of interventions on the Secretary of State earlier. Consultations are a sham and in places there appears to be a hopeless lack of engagement with clinicians. Solutions that may well be ill thought out are imposed from above. Those who work in the service are often left with no confidence in the decision-making process.
	The whole process got off to a pretty inauspicious start in September last year when the newly appointed chief executive of the NHS was reported in  The Guardian as announcing that there would be up to60 reconfigurations of NHS services, affecting every SHA in the land. That did not sound to me like an invitation for local trusts to consider their options for service delivery and to take their own decisions. It was the head of the NHS saying that there will be reconfigurations.
	The Secretary of State, however, insists that the whole process of reconfiguration is locally determined. In October, she told the BBC:
	It's got to be done locally. The local NHS, the doctors and other front line staff sitting down with each other and with the local public, to work out what is the best and the safest way of providing healthcare to the people in their area.
	Let us test how much that is the case in practice.
	Decisions about reconfigurations are the responsibility of the primary care trusts working together with the strategic health authorities. I want to say a few words about the role of the SHAs and about my experience in the East of England region. I suspect that if we asked average members of the public what the SHA does they would not have the faintest idea. Yet we have seen in the East of England region and across the country how they wield enormous power in a way that totally lacks transparency. Where does accountability lie for SHAs? It lies, of course, directly with the Secretary of State.
	We have seen the influence of the SHA in Norfolk, where a new PCT was established in October. A lady called Hilary Daniels was appointed as the acting chief executive. Back in August, the person who had been appointed as the new chair of the PCT announced in a letter to staff the intention that Hilary Daniels, previously the chief executive of the West Norfolk PCT,
	will hopefully become interim Chief Executive either until a substantive appointment is made or by the end of June, 2007.
	Hilary was a highly regarded chief executive and West Norfolk had been well and efficiently run. However, by 24 January, a press release from the PCT declared that Hilary
	was delighted that she is now able to bring forward
	her departure. What wonderful spin! The truth, I am told, is that she was forced out by the SHA.
	I have spoken to consultants in the East of England region who have raised concerns with me about the extent to which the SHA was involving clinicians in the development of its plans for the reconfiguration of acute hospital services. The truth, I am told, is that the level of engagement appears to be minimal. One comment from a clinician was that they were
	utterly out of the loop.
	I remind hon. Members of the Secretary of State's comment in October about local health services sitting down with clinicians and the public. Here we have a clinician in the East of England region saying that clinicians are
	utterly out of the loop.
	Perhaps to provide some reassurance of genuine engagement, the SHA announced that there would be a major stakeholder event in January. The only problem was that it forgot to tell the stakeholders. I heard from another senior clinician that they heard about it only four days before the event was taking place. They passed on the information to the union, which had not heard about it either. What extraordinary incompetence from the SHA. The result is that the clinicians feel that they have no confidence in a process that ignores their concerns. Of course clinicians should not dictate the process, but surely they should at least be listened to.
	Going back to the Secretary of State's comments from October, the whole approach was supposed to involve centrally doctors and other front-line staff in shaping the proposals. That is certainly not happening in the East of England region and I suspect that it is not happening elsewhere.

Norman Lamb: If the Minister would like to intervene, or to respond at the end of the debate, I would be interested to hear more about that. None the less, it appears that the number of cases in which the view of the overview and scrutiny committee is supported represents only a tiny proportion of the total. The process rarely seems to lead to a change in the proposals. So much for the local NHS sitting down with the public to decide what is best for their area. It is a sham, and the Secretary of State knows it.
	Can we be reassured that local primary care trusts are centrally involved in designing proposals for reconfiguration? Sadly not. They are not locally accountable in any sense. Their boards are appointed centrally by the NHS Appointments Commission and we know just what happens if they fail to toe the line: their chief executives get sacked, as we have seen in Norfolk. That is the reality. This is not local decision making. PCTs with centrally appointed boards are kept in line by strategic health authorities whose boards are also centrally appointed, and which are accountable only to the Secretary of State and operate in the shadows without any adequate transparency. Is that really the Government's idea of local decision making? Such a thing does not exist in reality.
	The Secretary of State needs to understand that dissatisfaction with the whole process is growing out of control. It is not only her Cabinet colleagues who are objecting. There is widespread rejection of the way in which the matter is being handled, and of the motivation behind it. It is all too easy to use expressions such as, This is Labour's poll tax, but that view is spreading. If we google the words reconfiguration and poll tax, we realise that that expression is being used more and more acrossthe country. In December,  The Guardian identified50 campaigns around the country and talked about the most widespread unrest since the poll tax revolts ofthe 1980s.
	I must express my severe doubt as to whether the Conservatives would do things any differently. Their motion talks about the need for a stronger local democratic voice, but the hon. Member for South Cambridgeshire (Mr. Lansley) did not tell us what that voice should be. I would be interested to hear more about what they are actually proposing in that regard. I suspect that, in reality, the process would be very much the same as the one that we have experienced under this Government.

Charlotte Atkins: The NHS has had too much change, which is demoralising and disruptive for both patients and staff. Some change, however, is necessary and desirable.
	Our Health, our care, our say set clear goals for the transfer of services to community settings. That is particularly welcome in a rural setting such as Staffordshire, Moorlands, where a round trip to the acute hospital can be more than 60 miles. In my primary care trust area, community matrons help people better to manage long-term conditions such as heart disease and diabetes, improving their health and quality of life as well as reducing hospital admissions. With an increasingly elderly population, falls are a huge concern and Leek Moorlands hospital now has an innovative falls programme to prevent falls and to help patients manage better after a fall. That saves lives, builds confidence and encourages independence, keeping elderly people out of hospital and living in their own homes, where they want to be.
	That is not all. My local community hospital, Leek Moorlands, has a minor injuries unit which is open every day from 8 until 8, with minimal waiting times. In addition, PhysioDirect offers telephone advice and treatment, without having to see a doctor first, for the whole range of neck, joint or muscular problems. There is also the deep vein thrombosis diagnostic service, which allows 200 patients from Staffordshire, Moorlands to be diagnosed and treated locally each year. That is a huge improvement for patients who would otherwise have to travel to Stoke-on-Trentagain, a round trip of about 25 miles.
	All of that was initiated by my local primary care trust, which was going to be swallowed up by a gigantic Staffordshire-wide primary care trusta reconfiguration too far. Although the Shropshire and Staffordshire strategic health authority steadfastly refused to take on board public opinion, the expert external panel and Ministers listened and supported my local campaign and we kept a local primary care trust, which has delivered for local people. Therefore, the public consultation did work and local health bosses were forced to accept its result.
	Effective consultation with patients and public is essential, not only for the reconfigurations that I have mentioned, but to ensure that redesigned services truly benefit patients. The chairman of my overview and scrutiny committee, Councillor Mahfooz Ahmad, has worked tirelessly with the local PCT to spearhead the campaign to establish a local health centre and GP surgery in Cheddleton in my constituencya fast-growing village with about 6,000 residents and no GP. The PCT is rightly responding by carrying out its own public consultation to ensure that there is a real demand for that service. I hope that we will soon see a GP practice in that village.
	With all that happening, is it surprising that there is a huge impact on acute hospital services? The number of hospital beds nationally has decreased by a third in the past 20 years. That does not mean, however, that the amount of care has decreased; on the contrary, it has increased dramatically. We must judge the NHS by the number of people it keeps well and makes better, not by the number of beds. My local acute hospital, the University Hospital of North Staffordshire, has buildings spread over three sites in an area of more than 90 acres. The age of the buildings ranges from less than 10 years to more than 150. That leads to huge problems and inefficiencies as services are split and patients have to be transported between different buildings and sites during their care.
	Our fit-for-the-future project will rightly create a new state-of-the-art hospital. It will have fewer beds, but that is because out-patient appointments will take place in clinics and health centres closer to people's homes, and patients will return home or to community settings more quickly when their treatment is complete. Already, the central out-patients department is cutting its service by 20 per cent. because of fewer GP referrals.
	Another change that I welcome is the decision to press ahead with the new maternity and oncology building, with the 65 million being funded from the Department of Health, rather than the private finance initiative. That will be completed in 2009. The cancer centre will be a purpose-built facility bringing together all day case in-patient and radiotherapy activity within one building. The new development will also bring together surgical and non-surgical management of cancer on one site for the first time.
	At present, the oncology ward and radiotherapy services are located half a mile from where patients undergo surgical procedures for cancer treatment. All those buildings date back to the 19th century. The Secretary of State had the opportunity to see some of them. She asked when she visited the hospital, Are these the worst buildings? We had to tell her, No, these are some of the best. The maternity unit will offer a modern purpose-built facility based on the separation of a low-risk midwife-led model and a higher-risk medically led model. It will deliver the modern standards of privacy and dignity that every mother has a right to expect. The present facility just does not deliver that.
	Parts of north Staffordshire are among the worst 10 per cent. of areas in England for deprivation. Almost 70 per cent. of the local population are among the 20 per cent. of the English population who have the lowest life expectancy, yet in the past north Staffordshire has been badly let down by Governments on health care. We are now at last getting the services that we deserve.

Michael Mates: Indeed it is not, and I am glad to have heard a more personal experience of maternity services than I have, although I did have to take a leading part in fighting the campaign on behalf of all the mothers in Petersfield. My worry is that, having just got back our services in Alton and Petersfield, they will be undermined once again, this time because of payment by results and yet more NHS reorganisations.
	The endless reorganisations of the NHS over the past decade is another major problem. I will not bore Members by listing them all, but I simply say that I do not know how anyone can expect high quality services to be consistently delivered in an organisation whose managers seem to change responsibilities on an almost monthly basis. Those reorganisations have caused bewilderment to the public and confusion to managers and staff, and they have inevitably affected both services and morale. It is confusing enough for Members and their staff to deal with those constant changes of structure and personnel, and it is near impossible for the general public.

Bob Spink: Does my right hon. Friend share my concern that the independent sector treatment centres, which is one of the latest reorganisations forced on the health service, will take the more routine cases that cost much less than the more complex cases, and that those more complex and costly cases will be left with the general hospitals, so they will have to foot the bill for them? Does he think that the budgets of the respective organisations should be adjusted to reflect the actual costs of the cases with which they deal?

Michael Mates: Yes I do; my hon. Friend's point is valid.
	NHS administrators are not a popular group, but they do an essential job. I know that their morale locally is low. It is unfair to expect people constantly to reapply for their own jobsto give just one example of why morale is low. It is also wrong to blame managers for the consequences of ill-thought-out reorganisations pushed through by Ministers without proper consultation. A recent survey of civil servants in the Department of Health found that just 4 per cent. of senior officials think that the Department manages change well; 81 per cent. do not. Who on earth, one might ask, are the 4 per cent.? They must be so high in the stratosphere of Richmond house that they simply do not know what is going on. The Department has been disastrous at managing change, and all its senior managers ought to know that.
	A further factor in the current difficulties is that these reorganisations and the confusion that they have created have led to a return to some of the slipshod practices that we thought we had left in the past. I was recently contacted by a constituent who had a post-operative appointment to see her surgeon after a hip operation in December. The lady, who is in her 80s, travelled from Petersfield to the hospital in Gosport last month, only to discover on arrival that her surgeon was off sick and his theatre list had been cancelled. No one had thought to warn the out-patient department that his clinic had also been cancelled. Despite being in pain, my constituent was then offered a new appointment in April. At that point she complained to me, and when I telephoned her she was in tears because she had just had another letter saying that her appointment had been put off until June. We have managed to sort things out, and she was seen last week. Such slip-ups might seem very minor to Ministers sitting in London and to officials in Richmond house, but they are crucial to the patients themselves. To judge by the number of letters that I receive about small but significant incidents of that kind, there is a deterioration in the NHS's ability to deal with these matters.
	Two other issues that are contributing to the current problems strike me as being of great concern. The first is the consequences of the introduction of the National Institute for Health and Clinical Excellence and its assessment of treatments. NICE's creation has led primary care trusts and NHS trusts to argue that a particular treatment should not be provided, on the ground that it has not been approved by NICE. The Minister will quite fairly say that that is not Government policy. Trusts can prescribe medicines and treatments that have not been approved, on the basis of their own assessment, but in practicethis is what really mattershospitals and PCTs do not generally prescribe drugs unless NICE has cleared them for general use across the NHS. There are examples of hospitals and PCTs approving individual items, but that simply demonstrates a return to the postcode lottery that I thought NICE was created to stop. The effect has been the stymieing of the introduction of new treatments that might have realin some cases, life-savingbenefits for patients.
	Secondly, such difficult cases are further complicated by existing NHS rules on the use of private treatment. There is a young father in my constituency who suffers from advanced colorectal cancer for which a new drug is now available: Avastin. However, his local NHS trust will not prescribe it. He decided to pay privately for Avastin because he was told that it was the only way that he could prolong his quality of life and, indeed, his life itself. Now, he is obliged under NHS rules to pay for all the other NHS treatment that he needs as well. I can understand that the NHS does not want to become a provider of private-sector services free of chargethat would make nonsense of the free at the point of delivery principle under which it has always operatedbut in my constituent's case, the rigid enforcement of these rules means that he is forced to pay not only for the drug Avastin, but for all the other treatment that he would otherwise be entitled to receive free. His consultant considers that scandalous. My constituent thinks it intolerable, and I and doubtless many others think it quite unacceptable.

Michael Mates: That is the point that I have been trying to make, and my hon. Friend reinforces it.
	There are two potential difficulties on the horizon. One of them, the move towards larger hospitals, could become a reality quite quickly. For more than 10 years, the Royal College of Surgeons has argued for a smaller number of larger hospitals. It is true that district general hospitals have emerged as a patchwork of provision, rather than in the systematic way originally intended. However, the public are deeply concerned by the notion of having fewer but larger hospitals further away from where patients live. That issue is especially important to those of us who have large rural areas in our constituencies, as many of my colleagues have mentioned. There is inevitably a delay in getting an ambulance to an urgent case in a rural area and, once the patient has been stabilised, in getting them to hospital.
	Fewer but larger units may make sense in large urban areas, but much of England is a mixture of large market towns and smaller rural communities. Many of those towns have had district general hospitals that now face closure of the whole or part, such as the accident and emergency service, as many hon. Members have mentioned, and the transfer of services to larger and more distant regional units. That does not improve services for those of us in rural areas.
	I simply warn the Minister that when my party set out, on the strong advice of the Royal College and other experts, to undertake such a reconfiguration of services in London, which might have made some sense, the Labour party used that as a stick to beat us with in election after election. To pursue a policy that could see three quarters of accident and emergency units in England closed would not only be of dubious medical value, but would be incredibly unpopular. Ministers can try to close only hospitals in Conservative-held seats, and some of my colleagues would claim that such a programme is already under way, but they should not imagine that they will get away with it.
	The whirlwind of change of the past few years shows no sign of slowing down. Local maternity services are under threat again, local accident and emergency units are being questioned and long-established hospitals serving large catchment areas arewe are toldno longer big enough for the new NHS. The financial position of community hospitals remains uncertain. All that is happening without the support of many of the Government's own Ministers, whoas we have seenhave taken to the streets to campaign against the effects of Government policies. That is a remarkable breakdown of collective responsibility.
	Without a period of stability and continuity, the NHS threatens to go into a permanent decline, as it struggles to provide the care that patients need and for which they feel, as taxpayers, they have more than paid over the years. If Ministers think that they can carry on pushing change through the NHS regardless of public or political reaction, they are mistaken. No amount of careful planning with heat maps or other tricks will avoid the inevitable and disastrous consequences of the Government's approach.

Frank Cook: It is a pleasure to follow the right hon. Member for East Hampshire (Mr. Mates). I hope to introduce a note of amiability into the debate by agreeing with his comments on Avastin. The issue requires serious investigation and perhaps correction, but one needs the full facts. However, the hon. Gentleman's comments on accident and emergency services are worthy of more corrective comment. In my view, it is crazy to have accident and emergency facilities open 24 hours a day if we do not have accidents and emergencies happening 24 hours a day. Therefore, we should have some form of scheduling. We have already had the comment from my right hon. Friend the Secretary of State that victims or casualties do not necessarily have to rely on road borne ambulances. In the same way, we no longer rely on handcarts, as they did in the middle ages.
	I returned from Brussels this morningI was on NATO parliamentary assembly businessand I was not sure that I would get a chance to contribute to this debate. I thought that we might have a sensible exchange about patient needs and community care, but for the most partespecially at the beginning of the debatewe have been treated to the standard Supply day swill bucket that we were used to years ago. Frankly, that does no credit to the health service or the patients who require it, and it does discredit to the Opposition that they cannot marshal their arguments in better form or put them in a more presentable way.
	Let me give some examples of what I mean. The hon. Member for Ribble Valley (Mr. Evans), who is not present in the Chamber at the moment, accosted the Secretary of State with the comment, Were you right then, or are you right now? You can't be both. Well, of course she can. Times change. If someone says one thing three months ago and makes a comment on it today, times have changed in between, so they can be right on both occasions. But perhaps that logic is a bit deep for some of the characters on the Opposition Benches.
	The hon. Member for South Cambridgeshire (Mr. Lansley) made a similar remark when he kindly referred to the hospital provision on Teesside. I am talking about the general hospital in Hartlepool and the University hospital of North Tees. He reminded the House of the comments of the then Secretary of State for Health and the then Prime Ministerhe is still Prime Minister now, I ought to remind the hon. Gentleman. He commented that he did not know whether the report was right or wrong. I can tell him that it is in fact wrong. The comment that was made then is right, but the inference that he put on it is wrong.
	The report from the independent reconfiguration panel states that a third hospital will be provided. I ask the hon. Gentleman to put on his planning hat. If a third hospital is ultimately providedat the moment the services that will be included in that hospital are still under considerationas the services there develop and become established, that third hospital will withdraw specialisations from the other two. I hope that that principle is clear. I can see nodding, which is good. As those specialisations are withdrawn, the other two hospitals, in Stockton and Hartlepool, will reduce in size and so take on the character of less acute attentive clinics, which will enable the footprints of both those hospitals to decrease and therefore enable some of the property to be

Frank Cook: I accept the statement of opinion that is being given [ Laughter. ] I do not find this amusing at all, funnily enough. Is the House simply interested in ridiculing the efforts that are being made on the provision of medical aid to patients?
	Let us look at the principle: as one hospital builds up its services, the others will run down their services. That has got to happen. There will be in place primary care, with the paramedics, nurse practitioners and the general practitioners in their health clinics. Secondary care will be provided in the Stockton hospital of North Tees and Hartlepool general hospital, which will take care of less acute need. Tertiary specialist care will provided in the new hospital[Hon. Members: No.] Well, that is what reconfiguration means in my head, and it makes sense to me.

Frank Cook: The hon. Gentleman seems insistent on reintroducing Professor Ara Darzi when he was disposed of some time agonot as a personality, but in the form of his report. The Opposition must get their head around the problem. The hon. Gentleman's colleagues want a cardiologist on every corner. They seem to think that there should be every provision on every street so that people do not have to travel anywhere, but that is not possible in today's times and with today's needs. We should be providing for needs only where that is neededit is as easy as that. We cannot have specialist provision in every village.

Nicholas Soames: Well, that is all very clear. I am sure that we will be rewarded by a close study of  Hansard tomorrow.
	It is a privilege to speak again in a health debate after my right hon. Friend the Member for East Hampshire (Mr. Mates). He and I share a number of things in common, especially the fact that both our constituencies have been burdened since 1997 by several reviews of their local areas' hospital services. In Mid-Sussex alone, there have been four such reviews since 1997, each with a more ludicrous name than the last. The penultimate one, Best care, best place, took place in 2004, and 18 months on, the whole health service in West Sussex has been thrown into confusion by another paper, Creating an NHS fit for the future.
	Those reports were subsequent to a document commissioned by the West Sussex health authority, which, in 2000, faced growing fragmentation in health care provision, escalating and disproportionate management costs, and rapidly accumulating debts. The authority turned to Michael Taylor, a senior executive at the Oxfordshire health authority, and asked him to report back to it. Taylor exposed a series of top-heavy management structures in expensive premises, and duplication, replication and wastefulness. No one paid any attention to his warnings and the wilful mismanagement of the NHS in West Sussex continued, leading to colossal debts of over 100 million.
	We have discussed the subject before in similar debates, but the Minister of State, Department of Health, the hon. Member for Leigh (Andy Burnham) has given no answer on the issue. Sadly, as many colleagues would agree, when the Best care, best place consultation began in November 2004, it was regarded as a total sham in my constituency and elsewhere. Regretfully, West Sussex county council's scrutiny committee failed to do its duty, and did not call it in. I want the Minister to understand that the management of the strategic health authority, and most specifically the primary care trust, represented the paper to my constituents and to me as the way ahead for the foreseeable future. Many of my constituents were deeply cynical about the Government's motive, but they went along with it.
	On 7 June 2005, at my suggestion, Professor Sir George Alberti, the Department of Health's so-called accident and emergency tsar, came to a meeting in the boardroom of the Princess Royal hospital to discuss the changes put forward in Best care, best place, the penultimate reconfiguration that my constituents have been obliged to endure. In that meeting, he persuaded me, against my better judgment, that it was right to make the proposed changes to the accident and emergency services, and particularly to switch major trauma cases from Haywards Heath to a hospital in Brighton, because of the necessity of treating major traumas on a site where all the main services were present. I still believe that to be the case, but at the end of the meeting he made it absolutely plainI have it in the minutesthat
	had he taken a blank piece of paper to design the services for the given location with the same geography, patient flows, he felt that the presented solution was the best fit and would have been the one that he came up with.
	Sir George went on to state in the same minutes that there were
	significant benefits to be gained from the reconfiguration,
	particularly for the Princess Royal hospital.
	Many of my friends, and colleagues of all parties, who attended that meeting were deeply cynical about what Sir George Alberti said, but I supported it. I must report to the House, however, that, not 18 months later, it is probable that a further significant upheaval will be proposed. There will be further substantial changes, which may include the removal of an essential accident and emergency service at the Princess Royal hospital, to be replaced by a walk-in centre.
	As I hope the Minister is aware, we are talking about a part of the United Kingdom that already suffers from serious infrastructure fatigue. The hon. Member for Staffordshire, Moorlands (Charlotte Atkins) spoke about the health service in her constituency, but what she describes sounds like Versailles compared to what we have in my constituency, and compared to the investment that has been made in health and wider infrastructure in Sussex. Mid-Sussex alone has a statutory duty to accommodate 7,000 new homes between 2006 and 2016, and that equates to about 45,000 extra people, yet there is talk of closing an accident and emergency department in a hospital not5 miles from a major motorway. Gatwick airporta major international airportis up the road, and there is only one accident and emergency centre anywhere near it.
	There is appalling traffic on the roads into Brighton, and the infrastructure and public transport system are entirely inadequate to support the change. That change was proposed despite the assurances that I was given on the Floor of the House in an Adjournment debate that I secured on 16 March 2005 by the Minister's predecessor, the right hon. Member for Barrow and Furness (Mr. Hutton), who stated in volume 432 of  Hansard at column 383:
	There is no question of A and E services being downgraded or becoming a minor injuries unit. That is not going to happen.[ Official Report, 16 March 2005; Vol. 432, c. 383.]
	I urge the Minister to repeat that assurance on the Floor of the House. The removal of a full accident and emergency service is not right for my constituency or for my constituents and, between us, we will not permit it to happen. The Support the Princess Royal hospital campaign commands enormous local support, and it is an all-party cross-community effort that has attracted nearly 60,000 signatures. People have signed a petition to the effect that they will not tolerate the removal of their A and E, as they believe that it would be wrong to end that service. They want to preserve proper maternity services for a growing population, so it is essential that the Government listen to the clearly expressed views of large numbers of local people who believe that the proposals are completely wrong.
	The Keep Worthing and Southlands hospitals campaign has attracted more than 100,000 signatures, and the St. Richards campaign in Chichester has attracted 134,500 signatures. Will the Minister confirm that consultations will be held in good faith and that the strong views of local people will be accorded the respect that they deserve, as failure to do so would be a recipe for profound resentment and indignation? My hon. Friend the Member for Arundel and South Downs (Nick Herbert), who has played a detailed and effective part in that campaign, and I both accept that change is required. Changes can and should be made, provided that the infrastructure is in place. We will support those changes, but we do not support the removal of A and E and maternity services.
	It is the perception in our local health service and, I believe, in many other local health services, that our magnificent, hard-working nurses are engaged in a constant struggle to look after patients as a result of inadequate resources and facilities, yet local trusts appear to have limitless resources to hire more bureaucrats. Local people know that the local NHS operates in an Alice and Wonderland world of twisted targets and distorted figures, and I would not care to be the auditor who has to sign off NHS accounts. Doctors should play a far bigger role in patient careit is they who should be in charge of that care, not managers. The proposals in the Fit for the Future document are not better for patient care, as they constitute an effort directed from London to resolve the appalling mismanagement with which people failed to deal with or get to get to grips with in the past, and to absolve them of responsibility for the grotesque financial problems that have arisen as a result.
	Finally, I have two important points to make. First, the accumulated historic deficits resulting from poor management over the years and a lack of grip, together with the merger of the Princess Royal hospital and the Royal Sussex county hospital in Brighton, inevitably led to a large overhanging debt. I have referred to that problem on many occasions in the House, and we need a better, more constructive and imaginative approach to deal with those debts, quite apart from the necessity of making sure that the hospital is run prudently and effectively. The trust management is doing its very best to meet those demanding targets, but the Minister should meet it halfway, and I urge him to meet a delegation to discuss the matter. Secondly, the Government must review the funding formula in West Sussexa subject on which my hon. Friend the Member for Chichester (Mr. Tyrie) has consistently made a detailed case. I know that the Minister discussed the matter the other day with my hon. Friend the Member for Arundel and South Downs.
	The Princess Royal hospital is a first-class establishment and it has a highly skilled and dedicated work force that plays a vital role in the local NHS, in an area with vastly expanding requirements and inadequate general health infrastructure. There should be more services at the PRH to utilise fully this excellent local hospital, which would be in the best interests of local people and patients. Everyone knows that the hospital does an exceptional job, and with the right support and without the dead hand of Government with their arbitrary targets, that outstanding hospital could do even more. That is what I want to see, and I know that local people in Sussex share my view.
	In conclusion, we understand the need for change, but local people know when change is going too far. Patient care must not be compromised for financial considerations.

Howard Stoate: I welcome today's debate, not just because it gives us an opportunity to discuss the process and nature of hospital reconfiguration, but because it provides us with the opportunity to consider the wider question of what kind of role the acute general hospital ought to play in the 21st century NHS.
	I shall quote briefly from the NHS Confederation briefing, which states:
	Reconfiguration is needed to improve health outcomes. Changes are necessary whether or not there are NHS deficits. Indeed, in some cases the reason why trusts have run up deficits in the first place is because these decisions were not made earlier.
	The briefing goes on to say:
	We must start judging the NHS by the number of people we make better and keep well, not by the number of beds.
	That, to me, is perfect common sense. Much of the debate on reconfiguration tends to dwell, quite understandably, on the potential loss of local hospital services and the perceived reduction in the quality of local health care. That diverts attention from what ought to be our primary area of inquirywhy we continue to admit so many patients unnecessarily to hospital, and what we can do to prevent it.
	As I have said on many occasions in the House, the vast majority of hospital admissions should be seen as a failure of health policy. Every day thousands of patients are admitted to hospital not because they are desperately ill or because they need the support that only a hospital can provide, but because we often do not have anywhere else to treat them. In most cases patients enter hospital as a direct consequence of our failure to spot potential problems, to prevent people from becoming ill in the first place, and to put in place effective care packages that would allow them to be treated properly at home.
	One in four emergency admissions consists of people with chronic conditions who yo-yo in and out of hospital three or sometimes four times in a single year. That adds up to 1 million unnecessary hospital admissions each year, costing the NHS in excess of2 billion. This catastrophic waste of money rarely does patients any particular good. Not only do patients not want to be in hospital, but in many cases they would make a quicker and more complete recovery in their own homes and certainly in their own communities, supported by an appropriate care package close to where they live.
	Most policy makers and commentators understand that and sometimes even talk about the need to reduce unnecessary hospital admissions, yet progress is painfully slow, given the sensitive nature of reform. As we have heard this afternoon, too often the reason is thinly veiled political self-interest on the part of Members who understandably but, in my view, misguidedly try desperately to talk up their own area and their own interest, often to the detriment of the wider health service. We must try to redress that tendency.
	We are making some progress. Patients are discharged back into the community far more quickly than they would have been a generation ago, thanks to the increased use of less invasive procedures and the huge increase in day surgery. Today's hospitals require far fewer beds, as we have heard in the debate, and patients requiring minor procedures are increasingly being treated elsewhere. However, I believe that the model of acute care that we had in place is no longer fit for purpose, and we need to radically rethink the way in which the acute system, and the district general hospital in particular, is operated.
	We should start by asking which services must be provided at acute district hospital level. Although there is a range of services to which patients in each area need access, including trauma, accident and emergency, orthopaedics, paediatrics, obstetrics, gynaecology and many others, there is no reason why all these specialties should be provided at each and every acute hospital in a particular region.

Howard Stoate: As I am not an expert on the hon. Lady's constituency, I cannot possibly comment on what the local GPs want. I am making much wider points about the direction that the NHS should be taking.
	The duplication of services is vastly costly, and makes it far more difficult for individual hospitals to build up the specialties and expertise that they need. Would Members rather be treated by a unit that dealt with 10 cancers in a year, or by one that dealt with 200 in a year? I think the answer is fairly obvious. Why, then, do we need specialist cancer services in each hospital? I am merely making the general point that if services are configured in a way that concentrates the most expertise where that expertise is best delivered, everybody will benefit. We will avoid duplication, staff can build up much more expertise, and ultimately patients will receive a far better service. Such an approach would enable us to rationalise the number of beds significantly, and to save each trust hundreds of thousands if not millions of pounds without jeopardising patient care in any way. After all, a stay in hospital does not come cheap: it can cost up to 500 a night for someone to stay in an acute unit.
	There will obviously be some obstacles to the process that I wish to see. The way in which hospitals are financed and set up will have a bearing on the configuration that will be possible over the next few years, and I think we must look carefully at the way in which we establish and pay hospitals to ensure maximum flexibility. I make no secret of my belief that the payment by results system has sometimes presented an obstacle. It often makes reconfiguration quite difficult, because paying hospitals according to activity rather than results may give them an incentive to provide care that, in my opinion, would be far better provided elsewhere.
	As the House knows, I am a GP who continues to practise a certain amount. GPs have been given control of their budgets under the practice-based commissioning scheme, and in theory they can control their use of secondary services to a large extent, but the reality is very different. Many patients still attend A and E units off their own bat, and are treated, admitted and referred to consultants without any consultation with their GPs. Most of that treatment may be justified and necessary, but it is not possible for the primary care sector to have any control over it.
	I have been looking at the Dr. Foster data that is sent to my practice every month. What I have here is a month of data from my practice alone. It is extraordinarily difficult to make any sense of it. I asked my practice manager, an extremely experienced man, to try to do so. He told me that it had taken one member of staff three days merely to establish whether the patients on the list were registered with the practice, and that it was impossible to conduct any meaningful analysis of the data on a monthly basis. Ministers should bear in mind the fact that if we are to have access to data to help us make decisions, there must be a possibility of our understanding it.
	An elderly patient was taken to A and E with a nosebleed, which cost the practice 1,500. The practice was recently charged more than 200 for a hospital appointment that had been cancelled by the acute trust. Then there are patients whom we choose to refer to hospital for specific reasons, and who are then treated for completely different reasons. A patient whom we sent to hospital for a routine back operation surfaced 141 days later at a cost of 38,000 to the practice. I am not saying that that was not justified; what I am saying is that there was no way in which the practice could have had any input into the management of the patient, or any say in alternative pathways of care.
	I would go as far as to say that rather than there being a Berlin wall between primary and secondary care, there is a black hole. Not only do hospitals suck in enormous amounts of resources, but very little light emerges. We must look carefully at the interface between primary and secondary care to ensure that enormous amounts of information do not overwhelm our ability to ensure that patients are given the best possible treatment. I believe that the only solution is to provide more vertical integration between the primary and acute sectors. That, I think, is the only way in which to establish a meaningful dialogue between GPs and hospital-based consultants, and prevent hospitals from simply using the system for their own ends.
	I think that we have a lot to learn in that respect from the Kaiser Permanente scheme, which was cited in the White Paper as a successful example of integrated prevention-oriented health care. The Kaiser model owes much of its success in reducing acute sector activity to its decision to invest in a network of community-based specialty clinics in which primary care professionals work alongside specialists. The clinics have the facilities to cater for more or less every step of the patient's journey, from initial assessment, through diagnosis and treatment, and eventually to follow-up. The most important part is that, unlike in the NHS, there are no structural distinctions between the primary and secondary care sectors. Not only is the model vertically integrated, but the ethos is based on prevention, integrated working and the belief that the most effective and cost-effective care is that which is given as close to the patient's home as possible.
	It is highly questionable whether we can get the same benefits in this country without looking at a similar model of health care. We should give serious consideration to integrating primary and secondary care under the aegis of a single, discrete care trust. That must involve a radical change and is far more than just a rebranding exercise. We certainly cannot reduce hospital activity without looking at the incentives and how hospitals are managed at the moment to ensure that they are not driven simply by financial needs, rather than patient outcomes.
	We would need integrated care teams and properly set up community teams to ensure that most carethe vast majority of it can be given in this wayis given close to the patient's home. We would need professional executive committees that were powerful enough to make those decisions without being swayed by individual pleading. We would have to ensure that we avoided acute admissions as far as possible and that we did everything possible at primary care level to avoid the need for people to go into hospital with acute needs in the first place.
	I believe that all those things are perfectly do-able, but only with a radical rethink. On top of that, I am also calling for the setting up of a polyclinic-style clinics in each community. If we integrate the primary care sector with secondary care specialists, nurses, physiotherapists, occupational therapists and so on, most care can be provided at that level without necessarily having any acute in-patient beds in such clinics, which could do a lot of procedural investigations and minor surgery, again avoiding the need for acute hospital admissions. That would free up the hospital sector to provide the care that only it can provide. I believe that that would be a far more coherent structure for the health service.
	What is morethis is the most important partif such polyclinics were set up properly, it would be obvious to the patients that they were situated in their communities and that people were getting much better care much closer to home. Such an arrangement would also reduce the need for patients to travel to hospitals. It would not only be much more cost-effective for the health service, but it would gain the consent of patients. Indeed, at the end of the day, if we are going to reform the health service, it can be done only with the informed consent of the public. After all, it is they who pay for, use and benefit from the service, and we must ensure that they see the benefit for themselves.
	That is why I propose a radical rethink of the health service involving much more vertical integration and providing far more services far closer to home, based around the primary care unit. I think that such an approach would meet all our Government objectives, achieve good financial management and good husbandry, and use resources to the maximum benefit.

Andy Burnham: I am listening to the hon. Gentleman in amazement. Does he care to enlighten the House as to what the state of the health service in his area would be if his vote against the extra funding for the NHS through the national insurance increase had been carried? What vista would he see if he had got his way and the money had been denied the health service?

David Wilshire: My hon. Friend is right. I repeat the invitation to Ministers: come and talk to us, see the position for yourselves and try to justify it. Given events in Surrey, it beggars belief that the Government have the nerve to claim that the sort of review that we face is about improving services. That is an insult to my constituents' intelligence. Surrey PCT is running around, presumably at the Government's behest, waving documents called Clinical case for change, and telling people, Forget what we said last year; this is the justification for the cuts. That is a pathetic smokescreen.
	As I said earlier, last March, we were told that a hospital and an A and E department had to be shut to save money, but the document that is now waved about claiming that there is a clinical case for shutting A and E was not even commissioned till nine months after we were told the truth about the reason for the cuts. The documents are a smokescreen. They may contain some substance for the future, but if the debate is about improving services, why did not it start with the documents?
	If the debate is about clinical services, and there is to be genuine consultation, I invite the Minister to confirm in his winding-up speech that it will, indeed, be genuine and that he disowns the chairman of Surrey PCT when he goes around telling people that we can have as many petitions and demonstrations as we like, but they will have no effect because he has to make cuts. Will the Minister state that the consultation will be genuine and tell the chairman of Surrey PCT not to make such remarks, if they are untrue?
	I have always tried to conduct my politics here as calmly as possible. However, the Government have treated my constituents outrageously. I am angry on their behalf. I do not want them to suffer or die, but, rather than improving care, the Government increase suffering, according to consultants in my constituency. According to a consultant, rather than extending life for my constituents, the Government are putting their lives at risk.

David Wilshire: I have named him many times asDr. Bellamy, who was an accident and emergency consultant. He is on public record as saying exactly that some people will suffer and some will die.

David Wilshire: The Minister does not need to try and sack him; because of the way he was treated, he has already retiredbut there we go.
	A year ago we heard a smug speech from a Secretary of State who lives in a fantasy world. I am appalled at what she had to say this afternoon. I am appalled at what the Government are doing to my constituents. The Secretary of State, Ministers on the Front Bench and the Government as a whole should be ashamed of themselves.

Ian Austin: I start by thanking the Opposition for choosing this subject for today's debate, although I have to tell them that the national health service that we have heard described this afternoon is not one that the people of Dudley would recognise, as extra investment and new ways of working have delivered real improvements for patients.
	Over the past four years, Dudley PCT and the Dudley group of hospitals have radically reshaped the way that health services are delivered in Dudley. Our flagship 200 million hospital, incidentally, does not serve only my constituents in Dudley, North, as it provides a first-class service to residents of villages such as Kinver, Wombourne and Swindonin South Staffordshire, which is represented by an Opposition Memberand, indeed, to residents of Bromsgrove. The idea that the services are improved only in Labour constituencies is completely false. The new 200 million hospital is at the centre of the modernisation of health services in Dudley and has been matched by a far-reaching reform of community services to ensure that more and more personalised care can be delivered outside hospital.
	A range of new services has been introduced, which, along with existing services, is changing the way that care is provided. Many services have been expanded with new rapid care teams, and a pathways service for hip and knee patients has been expanded to take account of other services. Care closer to home is now proving effective, providing treatments traditionally found only in hospital in the comfort of patients' own homes. We also have new outreach teams working more closely with mental health patients in the community.
	New nurse consultants are a key part of our new model of careworking, for example, with the100 people who return to hospital most frequently. They intervene earlier and provide preventive care closer to home. As a result, a sample of 14 patients analysed shortly after the service was introduced showed 98 bed-day savings. The latest figures show that the average length of stay has reduced by more thana fifth.
	New case managers prevent admissions into hospital and speed up returns to the community. Those nursing teams are reducing emergency admissions to the acute services. As we heard earlier, one case manager alone prevented 88 admissions to hospital in just an eight-month period last year. Our new pathways service shows how partnership working between health and social services can provide high-quality care, starting and finishing in the community, for patients awaiting elective surgery. It has reduced inefficiencies in the system, ensuring that the patient is treated in the most appropriate place by the right person.
	We also have a new community heart failure team. Under the leadership of Rachel Harris, the chair of Dudley Beacon and Castle PCT, new community-based services and a new community-based palliative care team for patients with heart failure have been introduced. The team provides new services in health centres and clinics and an additional team of five nurses visit patients in their own homes.
	Those new services have resulted in emergency admissions avoidance for heart failure patients. Across Dudley we saw an 8 per cent. drop in heart failure emergency admissions in the last two quarters of last year compared with the last half of the previousyear. The PCT has reduced heart failure admissions by 16 per cent. and a neighbouring PCT, which did not implement a similar team, saw a rise of 10 per cent. over the same period. When it introduced a heart failure team based on ours, it saw a 23 per cent. reduction in the first year.
	That is not to say that everything in Dudley is perfectof course not. Things can never be perfect in every case and there are issues, for example, with chiropody services in the community. However, the truth is that none of the improvements that we have seen could have been achieved without the extra investment delivered by the Government and the new ways of working that the Government have introduced.
	Despite the Conservatives' warm words on the Order Paper about the NHS, it is impossible to say that they believe in the NHS or that they would adequately fund it in the future. The motion, which stands in the name of the Leader of the Opposition, claims to recognise
	the need to develop and improve acute hospital services
	and calls for more commissioning, yet the Conservatives voted against the extra investment that is paying for the 109 new hospitals that the Government are delivering. Indeed, the Leader of the Opposition said at the time that the investment needed to pay for those hospitals represented fiscal irresponsibility. He has committed his party to a new fiscal rule: the proceeds of growth rule.
	Whatever the Conservatives say in the motion today, that rule represents a pledge to cut public spending year in, year out. If that rule were introduced this year, it would mean that spending would be lower than it is under the Government's plans. This year, the difference between the Opposition's plans and the Government's plans would be 17 billion, and the gap would be bigger next year and in every subsequent year. Given that health service spending accounts for almost 20 per cent. of total managed expenditure, a 17 billion cut in public spending applied across the board would mean cuts to the NHS of at least 3 billion this year. That would mean fewer new hospitals than the 109 new hospitals that have been opened or are currently being built. It would mean a 150 million cut in the 750 million investment in the new community hospitals and services being built over the next five years.
	Hon. Members need not take my word for this. Whatever the Conservatives say today, let us remember what the Leader of the Opposition said about the proceeds of growth rule this year. He said:
	As that money comes in, let's share that between additional public spending and reductions in taxes. That is a dramatic difference. It would be dramatically different after five years of a Conservative Government.
	He also said that he wanted to replace public services for the poor with
	a profound increase in voluntary and community support.
	So all this talk about a new modern Tory party is simply empty rhetoric. It is making the old Conservative commitment to a small state and cuts in spending, with charities stepping in to help the most vulnerable. That is why the Tories cannot promise that they will not cut funding for the NHS.
	We should not be surprised about that; it is not a secret. Every Tory speech reveals the truth. They will not give us the details of which taxes they want to cut, which services they would cut to pay for that, or which bits of what they constantly call the big state they would cut. All the rebranding in the world cannot hide the fact that they are the same old Tories committed to the same old spending cuts. They would run down the NHS using the same old prescription of cuts, charges and privatisation.
	The truth is that investment in the NHS has doubled nationally since 1997, and that it will treble by 2008. There are now 32,000 more doctors and 85,000 more nurses. We now have the best-paid nurses in Europe and, by 2010 there will be more than 100 new hospitals. Nobody should wait for more than 26 weeks for an operationa transformation from the situation under the Tories.

Alistair Burt: This debate takes place in the context of health, but the backdrop is trust. The Minister should not be surprised at the treatment of the Secretary of State's speech by Conservative Members, as it reflects the sense of complete distrust for anything that she says about what is happening in the NHS.
	The Government are hoist by their own petard. We have not forgotten how the Labour party treated the health service in the run-up to the 1997 election. We have not forgotten the treatment by then Labour Members and parliamentary candidates of attempts to modernise the health service to assist patients or reductions in beds. We have not forgotten the screeching in the House about the prospect of privatisation. Ten years on, people have seen what is happening to the health service under Labour, and how the Government have turned on their head to put into practice the same things that they complained about in opposition.
	It is no wonder that there is a sense of complete distrust about what the Government do. That is the reason for the general distrust about the fiddling of waiting list figures. No one believes the waiting list figures in this country any more, because every doctor in the country, at both primary and secondary level, knows how the figures are manipulated so that the Government can then spout them.
	Sadly, that is the context in which debates on the health service take place, and it is a shame. I want to say good things about what has been happening in Bedford, and to relate that to the debate on the acute services review. I start from a position of having a father and a brother who work in the health service, and of having no private health insurance. The NHS really matters to me, and I am concerned about its future and how it is dealt with.
	In Bedford, the debate about reconfiguration takes place against a historical deficit of 11.9 millionan arbitrary calculation, to which I shall return later. There are difficulties in the eastern area, where, strangely, we seem to have a preponderance of poor managers, given the preponderance of health service deficits that do not appear in urban areas. According to the Secretary of State, that is all due to management, when we know that that cannot be the case.
	Bedford hospital has done well despite what the Government have done, rather than because of what they have done. The chairman of the Bedford Hospital NHS Trust, Helen Nellis, is standing down. She has given excellent service to the area. She is a loyal, committed woman who has worked her socks off to do what the Government wanted to bring the hospital up to the highest possible standards. Despite her efforts, she has seen the hospital's finances messed around with constantly. Cancer care outputs are extremely good at Bedford, partly due to the Primrose cancer unit, which was built by the community, not by the Government. Cardiac care at Bedford hospital is excellent. Both my mother and father have recently sampled that care and been tremendously well treated.
	Throughout the health service, we will find examples of good practice and improvement. That has happened year on year since the 1940s. It is bound to happen. Trying to make out that one Government stop all improvement, and that another create it, is nonsensical. However, recognising good care, good practice and hard work by Bedford hospital, nurses, doctors and all other staff and that there are improvements does not stop us from asking key questions about whether all the investment that the Government have put into the health service has produced the results that it should have produced, whether money is properly spent throughout the system and whether it is distributed fairly around the country.
	The acute services review puts into sharp focus the problems that hospitals such as Bedford hospital have in fighting with one hand tied behind their back because of the constant changes in the health service and its structure and finance, to which my right hon. Friend the Member for East Hampshire (Mr. Mates) referred. That makes it so difficult for any stability or continuity to occur. It makes it difficult to drive forward change with any sense that what happens today will be recognised in three or four years and be given a chance to work.
	My constituents are determined to ensure that the current acute services review in the eastern area is dealt with from the bottom up, not the top down, and that medical and clinical need take priority rather than the rather strange economics that affect the region. Let me give three particular reasons why the review is a matter of some concern. First, there is general scepticism. In Hertfordshire, three years were spent on the massive document Investing In Your Health, involving the whole community and producing the idea of a new hospital. That was overturned overnight. More than that, the new hospital was said to be outdated before it even got going. What system could produce such a nonsensical review and take such an amount of time? Therefore, no one has any confidence that the current review will necessarily produce anything different.

Anne Main: As my hon. Friend rightly says, most people accepted Investing In Your Health and the promise of a new super-hospital. In fact, it was widely toutedMinisters were saying all around the constituency that it was going to happen. Now we have seen the demise of the super-hospital, we cannot seem to get any explanation of the mess that my hon. Friend has just described. The Government have not explained why it was all going wildly and wonderfully in 2005, yet the minute that the then Minister for Public Health, the former Member for Welwyn Hatfield, and the MP who represented St. Albans both disappeared off the map, the hospital went with it. There is a degree of cynicism among my constituents.

Alistair Burt: My hon. Friend puts it well. Who knows what the current acute services review will produce and, once it has produced an answer, whether it will last and anyone will take any notice of it.
	Secondly, there is concern about the distribution of funding in rural and semi-rural areas. The Government have been presented with evidence of how that works. The concern is not that there are not problems in urban areas, but that problems in rural and semi-rural areas are treated much more lightly and not given the consideration that they should be given. That is why expenditure per head is lower. That is why, even though there is a lower number of hospitals per head of the population in the eastern area, there will be no attempt to rebalance that by producing new hospitals in our area, and the same degree of relative deprivation will continue.

Andy Burnham: The hon. Gentleman is well placed to comment on these matters because he previously represented a Greater Manchester constituency. Does he therefore accept that, for example, there are more GPs per head of the population in his current constituency than in his former constituency and that the difference is considerable?

Alistair Burt: Yes, it is true. I cannot spend any more time now on that point, but the Minister will have a chance to deal with it in his winding-up speech.
	What I have said is true, and that creates a concern: if the same pattern of funding underpins the acute services review in our region, how can we be sure that decisions about where hospitals will be placed will not be made on the basis of the economics of the area rather than on the clinical needs of my constituents?
	We also want to be sure that after the review is concluded hospitals and trusts will be able to get on with doing their job without the Government breathing down their neck and constantly making decisions about their funding and how they should spend money. The Minister knows about the current situation at Bedford hospital. There is a deficit of 11.9 million. That forces the trust to do some remarkable things that waste still more money.
	Last summer, the trust decided that it could not replace an orthopaedic surgeon, but the flow of orthopaedic work did not diminish as expected. At Christmas time, staff were made redundant and wards were closedthat happened under Labour, I remind the Minister. Now, in the new year, it suddenly appears that there is so much orthopaedic work to be done that patients' waiting times will hit the cliff edge of the new 18-week target that has been agreed, so more money has been found in order to make sure that that does not happen.
	In fact, the treatments proposed will be more expensive than would have been the case if the trust had been able to replace the consultant and follow a normal pattern of work from summer until the end of the year. More money will go into the private sector, and money will be spent on evening operations if the staff can be found to do them, because Bedford Hospital NHS Trust is now readvertising for staff whom they sacked just a few weeks ago in the round of cuts at Christmas time. If the Minister can sit before us and think that he is presiding over an efficient and effective national health service as far as economics and financing are concerned, I am extremely surprised at him. He has a mess in those regards, which he must deal with. How can we have any confidence in the review if that is the economic basis underpinning it and under which hospitals will run?
	If the movement of services into the community is to work, the GPs in an area must be able to take on the extra capacity and do the job required of them. I presume that the Minister agrees that that is the case. However, I recently spoke with Dr. Peter Graves, the chief executive of Bedfordshire and Hertfordshire Local Medical Committee Ltd, and he has passed on to me a series of concerns about GPs and the primary care service not being ready to meet the extra demands placed on them by the Government.
	First, GPs need to become trained to become GPs with special interests. Unfortunately, the resources for that are not available, so GPs cannot get the training that they need in order to take on those specialties. Secondly, there is an issue to do with training multi-skilled professionalsthe further training of other clinical professionals to cover the GP while he or she is carrying out semi-specialist services. Dr. Graves says:
	It remains very difficult to find appropriate training for nurses and other staff, and indeed difficult to find the nurses willing to undertake such training in the first place. In order to deliver Secondary Care services in Primary Care a multi-skilled workforce is essential.
	Thirdly, he talks about premises:
	The third aspect of this issue is around practice premises. Whilst there are some large purpose built premises in Central Bedford, which might have the equipment and space to undertake further services (should the staff capacity be available) many practices around the outskirts of Bedford and in North Bedfordshire remain totally inappropriate. We are reliably told that there is money available for the development of premises and yet we are having enormous difficulty accessing this and finding the necessary support to develop premises.
	My constituents' perception of the acute services review is, first, that it is underpinned by dodgy economics, as reflected in rural and semi-rural areas, and secondly, that there is an issue to do with the way in which the finance is handled, as hospital administrators are forced to work with one hand tied behind their back, never knowing what their financial regime will be almost month to monthduring the course of this financial year, some of them had to make 4 million-worth of savings and they were handed an extra 500,000-worth of savings in October because of a decision that involved deficits throughout the rest of the region.
	There is also the question of whether such decisions will be made from the top down, or whether clinicians and doctors will be involved. As my hon. Friend the Member for Hemel Hempstead (Mike Penning) said, a lot of clinicians feel that they are out of the loop. Doctors and clinicians are not going to take these decisions; they will be taken from above, by administrators and people directed from Whitehall.
	There is another problem. Once services have been reconfiguredonce the decision has been taken to take them from the hospital and place them in primary care who is going to do this work if the GPs have not been trained to do it and they do not have the necessary premises and staff capacity? We are heading toward a repeat of what we have seen in the past 10 years: well-intentioned efforts by the Government and huge sums of money being spent, but a real mess on the ground. As a result, their efforts simply are not effective.
	Unless the Government stop living in a fantasy land in which there is no criticism and the Secretary of State believes that everything is working as she wants it to work, there will be no real delivery for patients, doctors and our constituents. All that we Conservatives are trying to do is to point out those problems, and that the health service and the people who work in it deserve rather better leadership all round than their hard work, efforts and determination are receiving.

Laura Moffatt: Probably no other subject strikes as much terror in the hearts of Members as learning that there is to be a review of acute services in their area. I live in a constituency where that has happened and I want to share some of the experiences of the people of Crawley, and to tell Members that there is life after reconfiguration and there are excellent services to be hadif Members are prepared to be open-minded about what these services are about.
	We in this House are in a privileged position, in that we have access to information that our constituents would love to have. We have a responsibility to share that knowledge so that our constituents can understand what the drivers for a review of services are. I was very interested to hear the hon. Member for North-East Bedfordshire (Alistair Burt) argue that pre-1997, the then Labour Opposition were preventing the reconfiguration and modernisation of the health service. I wish that the then Conservative Government had taken the bull by the horns, realised that Crawley hospital was in desperate trouble and addressed the issues of underfunding, accreditation and the hospital's general decline. They have now been properly addressed, and in sharing such experiences I want to show that the interests of our constituents must come first.
	I completely understand that, as I said, such reviews strike terror in our hearts, but our constituents' interests must of course be firmly at the heart of our efforts. We have had review after review in my local area. I have heard many Members say, I am in favour of modernising, reconfiguring and providing a better service, but most are thinking, But don't do it in my patch, if you don't mind, because I don't want the hassle of dealing with the consequences. Unless Members are mature enough to tackle this issue, which has emerged time and again in contribution after contribution, the way in which politicians will be perceived will be a worry. We have a responsibility to understand the clinical drivers behind the proposed changes, even though we might not like them or want to accept them.

Tim Farron: The hon. Lady is right to say that hon. Members should consider all the issues when a review of acute services is taking place. One size does not fit all. In my constituency, the Westmorland general hospital faces closure of its heart unit because of the acute services review. There are clinical arguments for that, but there are also strong arguments for providing emergency services close to where people live. There is no point in having an all bells and whistles centre of excellence an hour away from where someone lives, so that they die before reaching that fantastic centre.

Laura Moffatt: I have had that put to me by several Members of Parliament and it is just a smokescreen for their refusal to get involved in reconfiguration. They do not attempt to understand the issues or communicate them to their constituents. In the midst of the review in Crawley in 2005, I did have to face a general election, and the fact that I am a Member of Parliament now puts paid to that argument.
	It is easy to take the populist view. I have watched Members of Parliament on local television saying, Oh, isn't it awful, isn't it dreadful? They do not want to listen to the real arguments. They just want to say that the problem is all about money so that they can survive whatever might happen. I urge Members to think more carefully about what they are doing because, in the future, we will have to answer for all our actions. Often, if we do not do what we think is right at the time, it will come back to haunt us later. I hope that Members will think about that carefully.
	We have undergone a reconfiguration in Crawley. Of course I did not like it or want it to happen. Of course I kept pressing the Secretary of State about it. I have pages and pages that show the action that I took to try to make people understand how difficult the decision was. I am not ashamed of that. I am aware that the people of Crawley would understand that these are difficult decisions and that one has to keep arguing to get the best deal for one's own communityas I did. But inevitably, because of the overwhelming clinical arguments in support of reconfiguration, the major accident and emergency department was consolidatedCrawley was never a major accident centreat East Surrey hospital.
	Those were difficult decisions for us all. However, that is not the end of the story by any means and the work does not stop there. Remaining engaged and getting the best out of local services is our responsibility. Because of all the issues that I outlined to the House earlier in relation to accreditation and making sure that we were serving the public in the best way that we could, it was important to make sure that our local GPs had control of our local hospital. Crawley hospital has been reborn. It has had 20 million of investment. I am a member of the local league of friends and this Monday we toured our new urgent treatment centre. We have stepped up the service in Crawley from a walk-in centre to an urgent treatment centre. That is going to open fully on 5 March. It took a lot of hard work to make sure that that happened. The local GPs have the hospital in their control and they are filling it with all sorts of services. We have a new stroke unit, a renal unit, a chronic disease management centre and services that the hospital never saw the like of before. The community can see that there is a point in supporting local services.
	The real issue that I wanted to raise today is that if any Member thinks that this change is going to end, frankly I think that they are being ridiculous. No matter what we say in the House, or how many times we speak to try to defend a local service, change within the NHS is inevitable. I predict that in 10 years' time PCTs will not exist. I firmly believe that there will be single budgets. Local authoritythe county authority or however the local government is set upand health money will be in a single budget, to address the needs of local communities. We have made a start on that in Crawley already. We are keen for social enterprise to apply and to have that single pot of money. If somebody could fall over because their carpet needs replacing or get cold because they need their heating repaired, that budget will be able to address those issues and the needs of our local communities.
	We will probably look back at  Hansard and think what a strange, old-fashioned debate this was, because in many ways the model that is being defended on many sides simply will not exist. I hope that it will not, because it has stifled development in the health service for many years. A holistic approach is needed, certainly in relation to elderly care, mental health care and many of the chronic diseases from which people suffer. Some 17 million people in the country suffer from chronic diseases and they need their care local to home. That is why what happens following reconfiguration is essential in making sure that those services are in place. That is precisely what we have been doing in Crawley.
	I know and understand that these matters are difficultthere is no question about thatbut there are opportunities to be had following reconfiguration. I urge hon. Members to examine plans seriously and, rather than just taking an oppositionist view, to attempt to understand that this is not just about money. Of course money is an aspect of the process, and of course there is an impact on budgets. My acute trust is the most indebted trust in the country and is trying to get itself back into order. Despite that, it is still developing services and delivering a much better service that it did 10 years ago. It is still able to move forward with new services and to develop community services. It is working in a way that is meaningful to my constituents.
	It was interesting to hear my hon. Friend the Member for Dartford (Dr. Stoate) talking about consolidation. I will finish with a statement made by the Royal College of Physicians and the Royal College of General Practitioners:
	Service provision should move away from the needs of organisations to the needs of patients
	hear, hear. It continues:
	The Colleges believe that specialists and generalists working in strong collaborative arrangements offer a major and unrivalled opportunity to improve the quality and safety of patient care and to reduce health inequalities.
	I do not think that there is much more to add to that.

Nigel Evans: There was one aspect of the speech made by the hon. Member for Crawley (Laura Moffatt) with which I agreed implicitly: we hear people saying that we must modernise the national health service, but not their bit of it. I was struck that that was almost a fly-on-the-wall statement about the Cabinet. Clearly, some members of the Cabinet want modernisation and efficiency savings in some parts of the country, but not if that affects their services. It is amazing that they are saying one thing in Cabinet, yet something completely different to their constituents, but that cannot be right. There must be consistency. As I said to the shadow Health Secretary, there was such a thing as collective responsibility at one time. People who are part of a decision should stand by it, rather than taking to the picket lines in complete opposition to policies that come forth from decisions made directly in Cabinet.
	I agreed with everything said by my hon. Friend the Member for North-East Bedfordshire (Alistair Burt). We sat together on the Government Benches between 1992 and 1997 and heard what the then Opposition were saying to us. Our opposition to many of the things that are happening in the health service today is far more measured, far more sensible and put in a calmer tonealthough we are still angry and frustrated about what is happeningthan that of the then Opposition. There was a lot of shroud waving from Labour Members between 1992 and 1997. We are seeing things happening in the health service in our patches that we do not like, so if we were to show restraint by not standing up in the Commons to expose deficiencies, we would not be doing our duty.

Nigel Evans: It is probably better in some parts, but in others it is not.
	Although the Government think that the changes that are being made will make the situation betterwe are yet to see whether that will be the casea lot of people working in the health service are worried about those changes. The hon. Member for Pendle (Mr. Prentice) raised that matter during today's Prime Minister's questions, so, as a neighbour of his, I will raise the same issue and ask the Minister to address it in his winding-up speech.
	I believe in localism and that services should be as close as possible to where the public are. I have previously raised the reconfiguration of the primary care trusts in the Chamber. Although people in Longridge were receiving all their services in Preston, all of a sudden they were asked to get a chunk of their secondary provision in east Lancashire, although they do not live anywhere near there. I am sure that the Minister knows Ribble Valley and is thus aware of how difficult it is for people from Longridge to go to Accrington or Burnleythey do not know that area. We want local provision. Locally, there is Longridge community hospital, which the Longridge GPs rightly use, and Clitheroe community hospital, a tremendous community facility. We want those to thrive and to be used, and I praise the staff who work in the health service in my patch.
	All of us will have received letters from constituents about problems and deficiencies of service. If it is proven that the service was well below what the public expect, provided that the problems are properly investigated and corrected, we can have no difficulty with that, but attempts to cover up deficiencies are completely wrong. To address the Minister's point, I am sure that all of us in the Chamber will know of examples of excellence in our own patch, but there are other matters that we need to address properly.
	The major point that I want to make is about the clinical assessment, treat and supportor CATSproject under way at the Royal Preston hospital. On 25 January, the  Lancashire Evening Post had the headline, Hundreds of NHS jobs face axe. The hon. Member for Pendle talked about a private company providing some of the care normally offered directly by the national health service in the fields of general surgery, rheumatology, urology, gynaecology, ear, nose and throat and orthopaedics. Those services will be provided by a South African company called Netcare. When I have held surgeries in Booths in FulwoodBooths is opposite the Royal Preston hospitalmany people have come up to me and said, We're really concerned about the CATS scheme coming into our area. They believe that it will result in job losses in the area, and that hospitals in Preston and Chorley could lose as much as 16 million in income because of money being diverted to Netcare. That could result in 360 NHS jobs being lost.
	I hope that the Minister can address that point, which has also been made by the hon. Members for Chorley (Mr. Hoyle) and for Pendle. I hope that he will answer a question that a constituent asked me: what if Netcare brings nursing care with it from South Africa, which is where the company originates? Will the Minister give an assurance that if the medical assistance is in any way, shape or form South African, he will look carefully to make sure that none of that medical care could be better used in South Africa, particularly given the HIV/AIDS pandemic that the country faces? I know that the Government have a policy on that, and I hope that he will consider the matter carefully.
	I received a letter from a local councillor, Mrs. McManus, who asks a few questions about the change in Preston. She asks what will happen if there is, as expected, a severe drop in income, leading to a reduction in services at the Royal Preston hospital, and she asks about a
	reduction of surgical experience for Junior/newly qualified staff. The type of operations to be undertaken by Netcare are the type that Doctors cut their teeth on before moving on to the big stuff.
	She also asks:
	Can the private company match the diversity of Diagnostic equipment available at the hospital?
	She asks how much experience the doctors working for Netscape will have, and we need to know that. The hon. Member for Pendle raised an interesting point earlier about the fact that there seems to be a lot of secrecy about the way in which the system will be financed. The figures cannot be made generally available. Will extra money be made available, or will the money be taken directly from the Royal Preston hospital's budget?
	I am sure that the Minister understands that Members from his own party are deeply concerned, as am I, to ensure the best provision for people who live in the Preston area. We want to ensure that we are not pouring one pool of money into another, but that total provision will instead be increased, and we want to ensure that the care provided at the Royal Preston hospital, which is excellent in the main, will not be damaged.
	I wish to conclude with an issue that has already been raised. Clearly, if we can keep people out of hospital to begin with, that is a good thing. I am sure that we all have constituents who have been told by their GP that they need a certain drug that will keep them out of hospital and keep them alive longer. If the National Institute for Health and Clinical Excellence has not adjudicated on that drug, it is for the local primary care trust to determine whether it should be made available. One of my constituents, Keith Ditchfield, has acute renal cancer, and has to pay 3,000 a month of his own money for his drugs. He goes to Germany, as he does not have to pay VAT thereif the drug was available here, he would have to pay VATand pays 3,000 a month for a drug that many experts believe is useful because it keeps him alive and gives him a better quality of life. Why has that drug not been made generally available?
	The Minister will know about Velcade, which has been made available in Scotland, but not in England. Some drugs are made available by some PCTs, but not by others, even though they help to keep people out of hospital. I urge the Minister to address the postcode lottery. Why can we not reintroduce a national health service in which people, irrespective of where they live, are treated according to need, and nothing else? If a drug is effective for patients in Scotland, it is effective for patients in England, so cost should not be the reason why people are not given the drugs that they need.
	When we had the world's favourite health service, everybody was treated equally irrespective of where they lived. Everybody pays taxes, and we all pay an extra 1 per cent. in national insurance to pay for the health service. Everybody, irrespective of where they live, should receive the same care and treatment from a national health service.

Roger Berry: It is a pleasure to have the opportunity to speak in the debate. Most of my contribution is critical of the Opposition motion, but I agree with the final clause, which calls for
	a stronger local democratic voice that will contribute to public confidence in the planning of acute NHS services.
	I believe in that very strongly, and I have always done so. When the Conservatives were in government, I served on the Frenchay health authority. When a decision was made to remove elected local councillors from health authorities, because we knew too much about local matters, I disagreed. I welcomed the Government's introduction of overview and scrutiny committees, although there is insufficient local democratic accountability, as the Oppositionand I agree with themsuggest in their motion. It is self-evident that that accountability is insufficient to exercise control over financial matters, and local councils would never have been allowed to find themselves in the position in which, sadly, some trusts and PCTs have found themselves. Similarly, it is important that the local community engages in consultation about reconfiguration from the outset, and that proposals are not bounced on to them.
	Like my hon. Friend the Member for Crawley (Laura Moffatt), I have experienced reconfiguration and I would like to explain why it improves health care. I agree with the hon. Member for South Cambridgeshire (Mr. Lansley) that we should listen to local professionals. Reconfiguration is the subject of the Bristol health services planwe are part way through the processthat has been developed precisely because local clinicians, doctors, nurses and other NHS staff have argued for years that it is needed. It is not the product of concern about financial or staffing pressures. That could hardly be the case, given that there are 30 per cent. more staff working in the NHS locally than there were 10 years ago. Nationally, the number of people working in the NHS has risen by 300,000 to 1,300,000. I find it difficult to take too seriously the argument that of all the possible reasons why we might have difficulties, those are due to a shortage of staff. The national health service has never had an increase in staffing such as the rate of increase that we have seen in recent years.  [Interruption.] I am aware that Opposition Members may be saying from a sedentary position that we should make doctors work longer hours and cut their pay[Hon. Members: We did not say that.] When comments are made from a sedentary position, I occasionally mishear them. I apologise. I heard staffing hours mentioned earlier, but that was by the hon. Member for South Cambridgeshire.
	My key point is that in the Bristol health services plan, the proposals were put forward by clinicians and have been put forward by them for many years, for three basic reasons. In the greater Bristol area, as in many other parts of the country, 40, 45 or 50 per cent. of people who go to busy accident and emergency departments could be treated in local minor injuries units. They do not need to go to an acute hospital for treatment. Minor injuries such as cuts and sprains could be treated locally in a unit such as the one that I hope we will get at the Cossham memorial hospital in my constituency.
	There are in my area, as in others, thousands of people who attend the major hospitals for out-patient clinics and diagnostic tests which could and, in my view, should be provided nearer where they live, in community-based facilities. We all know that, thankfully, we have an ageing population in this country. We should celebrate the fact that people are living longer. More people are therefore living with long-term conditions. They want to go to their local health centre or to a local community hospital nearer home. They do not want to have to traipse to an acute hospital for care and support unless that is absolutely necessary. So the first basis on which clinicians in Bristol have been arguing for reconfiguration is that far too many people are forced to go a fair distance to an acute hospital, when local health centres and community hospitals could provide that support.
	The second point made by clinicians was made earlier this afternoon, so I shall be brief. They argue strongly that acute and specialist services need to be concentrated in centres of excellence, so that patients who are gravely ill will be guaranteed treatment by people who have the expertise and the equipment to do the best job. Again, local clinicians in our area have said that the key obstacle to improving acute services is the legacy of acute hospitals on four sites. In the greater Bristol area, we have Frenchay hospital, Southmead hospital, the Bristol royal infirmary and Weston general hospital.
	It is true to say that to some degree the four hospitals provide different services, which can be a disadvantage. I have had constituents who have been sent by ambulance from one hospital to another. It is not self-evident that the more acute hospitals there are in an area, the better. It can mean that people are treated for one condition in one hospital and then, sadly, they are afflicted by another condition for which an acute hospital a few miles away is the specialist provider, so, while chronically ill, they are sent by ambulance from Bristol royal infirmary to Frenchay to Southmead and so on. I do not think that is a clever way to run a health service, but I am not a clinician. It is doctors, nurses and NHS staff in Bristol who have said that we should have not four, but three acute hospitals with accident and emergency departments.
	The big debate locally has also been about replacing old buildings. In 1997, we had a hospital service with 18th century buildings, pre-war buildings, converted second world war huts, portakabins and a hospital built by French prisoners of war. Hospitals were not in a very good material condition. It was clear to everyone working in the health service locally that despite the magnificent efforts of staff, there were some hospital sites that required upgrading in order that patients could be treated properly and in sound and safe conditions.
	In essence, the reconfiguration proposals in my area have not been dictated by financial pressures. They have been promoted by clinicians who argue that too many people have to go to acute hospitals for minor injuries, diagnostic tests and so on; that there is a clinical benefit in concentrating on specialist facilities, which everyone in the House accepts; and that existing buildings are unsuitable.
	The Bristol health service plan for reconfiguration was first presented in 2003. There had been talk of it for years, but nothing had happened. It was presented not because of financial pressures, but because the Government's substantial increase in investment in the NHS meant that resources were more likely to be forthcoming. Like other reconfiguration proposals, the plan involves transferring services from acute hospital sites to community settings closer to where people live, when appropriate. It also involves massive investment in Bristol royal infirmary, a new heart and lung hospital, new cardiology facilities in north Bristol and south Gloucestershire, and much more.
	The controversial question was this: if the number of acute hospitals was to be reduced from four to three, which site should no longer act as an acute hospital? Would the new super-hospital for north Bristol and south Gloucestershire be on the Southmead or the Frenchay site? I make no apology for the fact that I passionately argued the case for the Frenchay site, as did many others. An equal number, including my good and hon. Friend the Member for Bristol, North-West (Dr. Naysmith), passionately argued the case for Southmead. The one thing that we all had in common was that we accepted, as we still accept, the clinical case for a single acute hospital, which we believed would put our constituents' health in better hands.
	There was extensive public consultation, and there was overriding support for one acute hospital to serve north Bristol and south Gloucestershire. Local councillors of all political parties, through the local joint health scrutiny committee and by other means, supported the Bristol health service plan and its central proposal for one new hospital at Southmead or Frenchay. They also resolved that the choice of site should be left to the local national health service. Southmead was chosen. Obviously I was not happy, but I strongly feel that revisiting that decision would be damaging for my constituents and to others who live and work in Bristol.
	The decision was made on a clinical basis. It was not about finance or staffing, and it was not made by the Government. At the last election the Tories made a point of saying The Government are downgrading your hospital. That is absolute nonsense. The decision was made in precisely the way in which Conservative councillors in my constituency and elsewhere said it should be made. The members of the joint scrutiny committee said unanimously that there should be one hospital and that the decision should be made by the local national health service, and that is exactly what happened.
	The one Tory Member of Parliament representing the Bristol area was so exercised that he did not even submit a written response to the consultation exercise, keeping his options open so that he could criticise whatever resulted from it. My Conservative opponent did not bother to do so either. How do I know? Through the freedom of information legislation. It is brilliant: it is possible to find out that people are not doing things, just as it is possible to find out that they are.
	I am very sad that in my constituencyI hope it is not happening elsewhereTories are playing politics with people's lives. I hope that the Government will be very clear in supporting what local doctors and local national health service staff are saying. I urge

Jeremy Hunt: We have had a good deal of discussion today about how the reconfiguration of acute services will lead to improved clinical outcomes, but the vast majority of Members who are fighting to protect services in their constituenciesConservative or Labour, Back-Bench or Front-Bench, even members of the Cabinetwill say that it is a question not of clinical outcomes but of financial deficits. This is about savings, not services.
	I want to illustrate to the House why that is the case with reference to the Royal Surrey county hospital, which serves many of my constituents. Although I shall talk about one hospital in specific terms, I want to stress that all Surrey MPs are united in opposition to cuts or reductions in services to any of our constituents. We are four-square together on that.
	The Royal Surrey county hospital has the lowest mortality rate in the country, and it sees 99.5 per cent. of its A and E admissions within four hours, as against a national target of 98 per cent. and a national average of 98.5 per cent. The Secretary of State spoke earlier about the critical importance of A and E departments managing their admissions so that as many patients as possible were seen locally and seen at hospitals only when necessary. On that indicator, which is known as managing variety in A and E admissions, the Royal Surrey county hospital comes top in the country out of 303 trusts. It is in financial balance and was rated as good by the Healthcare Commission. It even received a 100,000 prize awarded by the Minister of State, Department of Health, the right hon. Member for Doncaster, Central (Ms Winterton), for real, significant and sustained improvement in performance.

Jeremy Hunt: I am grateful to my hon. Friend for his excellent intervention. A good illustration of precisely the point that he is making was given in the earlier discussion about primary angioplastythis important new specialist service that will apparently be made available by the reconfiguration of acute services. All three hospitals whose A and E departments are under threat of being closed or downgradedFrimley Park, St. Peter's in Chertsey and the Royal Surrey countyoffer primary angioplasty, so the result of closing any of those departments will be to restrict, not increase, access to that vital service.
	Why is it that we are talking about the closure of such a vital hospital, despite the incredibly impressive performance that it has shown? The average time that it takes my constituents to get through the doors of an A and E department after an accident or emergency is currently 52 minutes. That is dangerously close to what doctors call the golden hourthat vital 60 minutes in which it is vital to get people through the doors of an A and E department if their chances of a good outcome are to be maximised. That is important, for example, if they need a computerised tomography scan to identify whether they have a stroke or a heart attack, with the very different treatments that will result according to the diagnosis that is made. If the Royal Surrey county hospital loses its A and E department, the average time that it will take my constituents to get through the doors of an A and E department will increase from 52 minutes to 65 minutes. That means that more of my constituents will not get through the door of an A and E department within the golden hour than will do so.
	According to consultants, the result is that 2,000 additional people from my constituency who are in need of resuscitationthe most acute form of emergency, involving people who have effectively stopped breathingwill not get into an A and E department within an hour. Consultants are quite open about the impact; they are saying that people will die.
	Despite my anger with what the Government are doing, I am not suggesting that they have deliberately set out on a course of action that will cost the lives of my constituents, but that is precisely what will happen unless they are prepared to do three things. First, they need to tear up all the consultants' reports that they keep using as the basis of the reconfigurations, because although they are often excellent in theory, they bear no relation to what happens on the ground. I remind Ministers that it was reputedly a consultants' report that advised Railtrack to stop its ongoing programme of track maintenance in favour of a much cheaper policy of merely repairing tracks as and when they brokea policy that directly led to a series of appalling train crashes and, in the end, to the demise of Railtrack. This is the first day of Lent, so here is an idea for a Lenten resolution for Ministers: they should stop using consultants' reports to see whether they can wean themselves off the habit.
	Secondly, Ministers should go out and look at what is happening on the ground. It is no good their hiding behind the fiction that these are local decisions made by local people on the basis of local circumstancesthey are made on the basis of a policy framework decided by Ministers and a financial framework set by the Government. True leadership involves getting stuck into the detail so that Ministers really understand what is happening.
	Finally, Ministers need to start to think about the root cause of these problemsnamely, fundamental flaws in the funding formula, which massively underweights age as a factor relative to social deprivation. Of course, socially deprived areas have additional needs in terms of health care, but the current weighting is very skewed against age. My constituency has a lot of older people, and as a result our funding allocation is increased by 2 per cent., but the lack of social deprivation means that it is reduced by 25 per cent. That cannot be right when all the evidence shows that the biggest determinant of demand for health care services is age, not social deprivation.

Jeremy Hunt: As ever, my hon. Friend makes an excellent and important point, which is backed up by strong evidence produced by Professor Sheena Asthana of the university of Plymouth who has studied the areas with deficits and identified a strong correlation between deficits and semi-rural areas with large older populations. It is not true to say that deficits are the result of poor financial management, because that is as likely to happen in an urban area as in a rural or semi-rural area.
	If Ministers decide to proceed blindly on, ignoring all the concerns expressed with the greatest sincerity by Members in all parts of the House, the anger in the country will make the poll tax riots look like a vicar's tea party. I could be cynical and say that the lack of marginal Labour seats in Surrey makes it unlikely that Ministers will show any interest in coming to Surrey to see what is happening there. We have invited them countless times, and every time they have refused to come. I would rather appeal to their better natures by saying this: the NHS was founded to help older people, poorer people and vulnerable people, and if they proceed blindly on with the plans, those are the people who will suffer as a result. For all their sakesfor the sakes of the people in South-West Surrey, Guildford, Woking and Surrey Heaththey should stop before it is too late and the lives of ordinary people are lost.

Iain Wright: The people of my constituency and the surrounding area have experienced uncertainty about the future of hospital services for approximately a decade. The recent set of recommendations from the independent reconfiguration panel, following its review of maternity and paediatric services, gives rise to more questions than answers.
	My interpretation of the IRP's recommendations differs from that of my hon. Friend the Member for Stockton, North (Frank Cook). I think that it recommends building a new hospital and closing the existing hospitals at North Tees and Hartlepool. It also recommends that specialist neonatal services for the whole of Teesside should be situated in the new hospital; that, in the interim periodwhich could last a decadeconsultant-led maternity and paediatric services should be centralised at the University hospital of North Tees, and that a midwife-led maternity unit and paediatric assessment unit should be provided at the University hospital of Hartlepool.
	To say that I am disappointed and feel profoundly let down by the decision is an understatement. The IRP's set of recommendations looks suspiciously like that which the County Durham and Tees Valley strategic health authority produced in 2003. Those recommendations stated that
	the long-term intention is to have one single acute hospital north of the River Tees.
	So much work and effort by a wide range of people was for nothing. That work included the observations of Professor Darzi in his review of a single-site option for the North Tees and Hartlepool NHS Trust. He said that
	neither the University Hospital of North Tees or the University Hospital of Hartlepool could provide services for the whole of north Teesside. Any single site option would therefore involve a major capital development. The timescales for such developments are often in the region of 7-8 years. As such, this would not be a solution to the issues facing the health service today
	Professor Darzi stresses today
	and, in particular, the need for rapid change to deliver sustainable, thriving, convenient and high quality services.
	The people of Hartlepool, who already suffer greater health inequality and shorter life expectancy than those in virtually any other part of the country, have experienced uncertainty about hospital services for almost 20 years. Staff at the North Tees and Hartlepool NHS Trust suffer similar uncertainty and a corresponding loss of morale and job satisfaction. That is unacceptable and runs the risk of undermining all the investment in the local health economy that the Government have made in the past decade.
	The panel's recommendations also disregard Professor Darzi's comments that the centralisation of all emergency services at North Tees or in an area away from the University hospital of Hartlepool would
	greatly reduce locally available urgent care services for the population of Hartlepool and Easington, who rely heavily on secondary care, ahead of
	I emphasise ahead of
	the completion of investment and expansion in primary care developments.
	Those are acute observations from Professor Darzi, and I will revert to those themes later. However, most importantly, the IRP recommendations also fail to take account of the wishes of 32,403 people who signed a petition, which I presented to the House of Commons, about the need to safeguard the viability of the University hospital of Hartlepool.

Iain Wright: I am actually grateful for that intervention. I hope that I made it clear that I feel profoundly disappointed and let down. More important, the people of Hartlepool feel profoundly disappointed and let down. However, if we consider the 50 years from the formation of the NHS to the election of a Labour Government in 1997, the Conservative party was in government for 35 of them. One reason for our relying on the hospital far too much through insufficient investment in primary care is Conservative Governments' complete failure to invest in primary care. We are now suffering the consequences.
	Let me proceed with the wishes of the people of Hartlepool. We should not be under any illusion about certain situations, as I think that regional health bureaucrats have a vested interest in running the health service and related matters according to their own specific wishes and requirements. I am profoundly concerned that public consultation is merely lip service.
	It may sound like I am arguing for the status quocarrying out the same services in the same way on the same site in the same buildingsbut I am not. I am ambitious and impatient to see advances in medical technology push health and clinical services out of hospitals and into the local communityeven into local people's homes. I agree with virtually everything in the document, Keeping it Personal, written by the national director for primary care and published earlier this month. I agree with the wish to take pressure off acute services and provide even higher quality primary care using multi-disciplinary teams from PCTs, social services and other agencies to co-ordinate and better manage all a person's specific health needs.
	I agree with the need to grow and develop NHS walk-in centres to relieve pressure on accident and emergency departments and I agree with the desire to see services such as those provided by GPs, dentists, opticians, pharmacists co-located in a single complex and even linked with other public services such as police and housing in a neighbourhood. I also understand and appreciate the drivers for specialisation and centralisation. I know that in order to receive the best specialist care, there is often a need to be treated in bigger more specialised hospitals. In such places, consultants are able to see larger numbers of patients, which means, in turn, that they can become specialists in their field, working with the latest equipment and with highly trained staff.
	The Government's vision, as advanced in the White Paper for health services, is for treatment to be concentrated more and more on primary care, while moving it away from a hospital setting. I believe that that is appropriate. However, I stress that Ministers need to appreciate that that vision cannot be rolled out across the country in a blanket fashion. If the NHS truly is a locally devolved organisation, the pace of change needs to be dependent upon local circumstances and to take into account an area's long-term health needs and socio-economic and demographic forces, coupled, crucially, with an assessment of the current state of primary health care in that area.
	I am a history graduate and a big fan of the principle that we cannot know where we are going unless we know where we have come from. That is why I believe that the pace of change will vary in different areas and should set the pace of any reconfiguration of hospital services. Pace should also vary. Professor Darzi's comments that I mentioned earlier are so valid because a move to centralise hospital services on a single site will not address the health needs of Hartlepool today and will put service reconfiguration ahead of primary care becoming embedded in the local area. The proposals for change to my hospital and hospital services simply put the cart before the horse.
	Primary care services in Hartlepool are underdeveloped and inappropriate for a town with such acute health needsa consequence, as I mentioned in my response to the hon. Member for Surrey Heath (Michael Gove), of a lack of investment for something like 50 years. My constituency has47.5 GPs per 100,000 weighted populationone of the worst ratios in the country. The Government are doing something about it, making Hartlepool a spearhead PCT with additional funding to tackle the problem of recruitment and retention of doctors, but I passionately believe that if services are to be pushed further off on a hospital site away from Hartlepool, that will highlight the acute need to have services brought into communities provided by GPs and associated primary care teams. The infrastructure and staffing need to be in place and developed. Frankly, despite progress in Hartlepool over the last five to10 years, I simply do not believe that we are yet in a position to do that.
	The same, I think, could be said for facilities within neighbourhoods. Throughout much of my life, GP surgeries in Hartlepool have been sub-standard. A recent estate audit in the town found that five of the17 GP premises in Hartlepool were in poor condition, with only six meeting the criterion for satisfactory. There is an acute shortage of space in those surgeries, which hinders their development and their potential to offer a wider range of services.
	Again, there are tantalising glimpses of what could be achieved. The Headland surgery has recently opened, providing comfortable and modern health facilities in the heart of one of the most deprived areas in the country. Alongside a pharmacist attached to the complex, the surgery has operating theatres available for day-patient cases, and the local authority has built a sports centre next door, emphasising the link between health and exercise. Local and co-ordinated health services provided in the centre of a communitythat is the future of the NHS in the 21st century. But that model needs to be rolled out extensively across the town, and that will take upwards of a decade.
	Hartlepool primary care trust has pledged to build a modern facility in the very centre of town, on the site of the former Barlow's building. This would provide reassurance to the people of the town that health improvements were being made and not merely being removed from them, by moving them out of town. This facility is planned to host a suite of GP and dental surgeries, as well as providing a minor injuries unit 24 hours a day, seven days a week for strains, sprains and cuts, in addition to a walk-in centre offering health information, sexual health advice and treatment for a range of minor illnesses such as coughs, colds and infections. This again is positive news, but the facilitywhich is being funded by the LIFT scheme, which was mentioned earlieris something like three years behind schedule. It needs to be provided as soon as possible to offer health services in the very centre of Hartlepool.
	It is little wonder, because of long-term inadequate primary care services, that the town has relied on the hospital. The number of admissions to Hartlepool's accident and emergency unit has risen by 42 per cent. in the past four years. This demonstrates the inability of many people in my town to access primary care facilities. A move to push health services further away from the population, without sustained and rapid investment enabling primary care infrastructure and facilities to be up and running aheadand I stress aheadof any further migration of services away from Hartlepool, would undermine any good will that Government's increased spending on health has achieved over the past decade.
	One of the key principles of health services is that they should be readily accessible. A hospital sited away from Hartlepoola town with one of the lowest levels of car ownership in the countrywould therefore be very problematic. In our debate on the future of bus services a fortnight ago, I described the poor service available for the people of my constituency accessing services at the University hospital of North Tees. The present site does not work, and any new hospital runs the significant risk of not working either, in terms of access to public transport. Any new hospitalnot to mention the present oneneeds to tackle the massive problem of access by providing a first-class transport system. I have already mentioned in the House the problem of congestion on the A19. That would be exacerbated by the building of a new hospital. Ministers need to work with all those involvedlocal authorities, local councillors and the local NHSto provide a practical and comprehensive solution to people's transport and access needs.
	As I mentioned at the start of my speech, the independent reconfiguration panel's report threw up more questions than answers. In order to address the important issues of community health facilities and transport, as well as the questions of where any new hospital would be sited, how it would be funded and whether it would be sustainable if it were to be small scale, I wrote to the Minister of State, Department of Health, my right hon. Friend the Member for Doncaster, Central (Ms Winterton), in January. I am pleased to see her on the Treasury Bench tonight. I hope that the meeting that we have arranged will be positive and will result in the start of real progress on the ground.
	Following the acceptance of the panel's recommendations by the Secretary of State for Health, the past month has seen the people of Hartlepool feeling battered, sore and let down by this Government. A great deal of work and co-operation will be needed to rebuild their trust. I hope that the Ministers on the Front Bench will start that rebuilding exercise now, by making a concerted effort to tackle the problems and concerns of my constituents, and doing what is right for the health needs of Hartlepool.

David Burrowes: I am pleased to follow the hon. Member for Hartlepool (Mr. Wright), and I recognise his passionate concern for his local community and about the lack of access to proper health care there. I share his concern, which I hope will be heard by the Minister, about his community being let down by the Government in relation to reconfiguration. I suggest that his reflection of the health care in his community is much more in touch with reality than that of the hon. Member for Kingswood (Roger Berry), who suggested that reconfiguration had nothing to do with the Government or with finance.
	Enfield is also going through the reconfiguration process, and Government and finance both have their hands on the reconfiguration plans there. That has been the case for a number of years. The plans have been talked about for years, as in other areas, but they were actually formed in 2003 with the healthy hospitals programme. It was clear from the consultation papers that the proposals were all about trying to manage what was then 22 million worthand risingof deficit, and trying to manage what was seen as a duplication of services. That, rather than clinical concerns, was at the forefront of people's consideration then and, sadly, it still is.
	The new clinical strategy sets out several criteria: one is to replace poor buildings at Chase Farm hospital; another is to make better use of the new facilities in Barnet; and another is to meet the clinical standards set out and required by the Healthcare Commission. Everyone would want to sign up to those. The final two are the driving forces: achieving and maintaining financial sustainability; and the national policy environment. The financial viability of Enfield is of great concern. The hospital trust is trying to deal with an 8 million deficit, and there are also London-wide financial issues, with a 90 million deficit to deal with. Those are the pre-eminent concerns for local people about the health care strategy.
	What was the national policy environment in 2005? It was outlined by Cabinet Ministers who made clear promises about health care to the people of Enfield during the election campaign. The Secretary of State for Defence promised a new 80 million building at Chase Farm hospital. The Secretary of State for Work and Pensions said categorically that the accident and emergency department at Chase Farm hospital was safe. That is certainly not the reality now.
	Consultation has been mentioned a great deal in the debate. The Secretary of State said that the consultation process was real, but I share the cynicism of the hon. Member for Hartlepool: lip service is paid to consultation. In Enfield, it is a sham. We recently received the leaflet, In Your Hands, though our letterboxesif only health care provision were in our hands. Local people and politicians are united in opposition to the plans. All the local Members of the Parliamentthe Under-Secretary of State for the Home Department, the hon. Member for Enfield, North (Joan Ryan), the hon. Member for Edmonton (Mr. Love), and my hon. Friends the Members for Chipping Barnet (Mrs. Villiers) and for Broxbourne (Mr. Walker)are united in opposition to the plans to downgrade the accident and emergency unit and to transfer the consultant-led maternity services. They are joined by all 63 councillors in Enfield, all the councillors in Broxbourne, a majority of GPs, some 22,000 people who signed a petition delivered to Downing street last year, 5,000 people who marched last December, the thousands who will no doubt march on 3 March to register their disapproval of the proposals, and the thousands who are signing the Hands off our hospitals petition each weeka campaign led ably by Nick de Bois in Enfield, North.
	The national policy environment now is the key driver. Certainly, it does not seem to be sensitive to what is happening in Enfield. Concerns to centralise services for care closer to home are often spewed out by Ministers, but they are not sensitive to the real needs in Enfield. The district general hospital model of the 1960s anticipated smaller community hospitals in clusters. In Enfield, the community hospital, which eventually became Highlands hospital, is now a housing development, and the concern is that Chase Farm hospital will follow the same path. That is a great worry, especially as Chase Farm hospital has a substantial catchment area and an accident and emergency department with admissions of some 20,000, and a maternity service with at least 2,000, a year. Health service managers, clinicians and others have not made the case as to where, if not to Chase Farm hospital, those seeking maternity services and accident and emergency care will go.
	We must therefore rely on the national case for change. What is that national case? Will there be better care through ever more centralisation of services? Let us look at the evidence. In relation to configuring hospitals for London, in 2004, the Department of Health concluded that research to date did not support
	any general prescription...that service concentration leads to improved outcomes for patients.
	Is there evidence of greater access to services? More recently, the Academy of Medical Royal Colleges made the point that bigger is not necessarily better, and pointed to the risks for those living in remote areas if emergency services are concentrated in fewer hospital sites. Enfield may be seen as just another concentrated suburb and site, but if we examine the catchment area in more detail, we see that it extends, for instance, to the constituency of my hon. Friend the Member for Broxbourne. If he were here, he would make the point that the lack of mobility, transport and services in Cheshunt means that access is a real problem for those in Enfield and beyond.
	The case that is made by the Minister and others is that primary care services will pick up what is left from those centralised services. Any reorganisation will depend on how those services in the community are organised and specifically on whether the community and primary care facilities can succeed in providing effective alternative services.
	In Enfield, the primary care trust is being top-sliced and is having to make 7 million savings. There has been 3.6 per cent. top-slicing in the past year. What is the reality of those primary care services? One only has to take the example of the baby care clinics that have recently been put further out of reach of my constituents. One sees the suspension of developmental checks. Primary care services are not necessarily improved when they are transferred to the community. We have improvements in diabetes, but it is not universal. The case has not been made out in Enfield that primary care services can pick up what is left from any downgraded Chase Farm hospital.
	Let us hear from the primary care managers. They say with reference to managing change:
	it will be very challenging to deliver the required organisational change, management cost savings, meet existing financial and service targets and play our full role in developing, consulting and delivering the...clinical strategy. There may be an element of planning blight with a slow down in the development of LIFT projects.
	Earlier in the debate, Members extolled the virtues of LIFT projects, but the PCT in Enfield says that that would be slowed down and suspended because of the impact of any downgrading of Chase Farm. That issue needs to be borne in mind when anyone considers the serious impact in Enfield.
	Let us deal with the finance. Would the changes provide better value for money? The local evidence is not made out and, nationally, it is variable. Cost-effectiveness seems to vary between different types of community or primary care-based services. In Enfield the Government have sought to rely not on local cases but on the Kaiser programme in California. They have sought to rely on that as evidence of how better value for money is provided within the community. But there one cannot treat like for like. There are considerably more specialists per 100,000 of the population in California than in the NHS. The case is not made out nationally.
	One only has to look at a recent report by the NHS National Leadership Network, which concluded that there was no guarantee that reconfiguration would necessarily lead to cost savings and recommended that the cost impacts of different service models should be monitored at a national level
	as a matter of urgency.
	The reality in Enfield and, as we have heard, beyond is that the case is not made out. Nationally, and certainly in Enfield, we are still waiting. One only needs to see the conclusion of the King's Fund:
	The partial nature of the evidence base and the potential for short term financial and political concerns to influence local decisions make it all the more important that there is real transparency about the costs and benefits of proposed changes.
	We have not seen real transparency in England. What is more important, local people need to be listened to. They are saying loud and clear, and will no doubt say loud and clear on 3 March: let us retain our A and E and our maternity services.

Michael Penning: May I say what a pleasure it is to follow my hon. Friend the Member for Enfield, Southgate (Mr. Burrowes), who has done so much to defend the hospital in his constituency. I praise him for that. I cannot be as kind to the Secretary of State for Health, whose speech some five hours ago was, frankly, complacent and patronising to my constituents and to constituents around the country who are so worried about health provision.
	I am pleased to have fellow Hertfordshire MPs alongside me, not least my hon. Friends the Members for St. Albans (Anne Main) and for South-West Hertfordshire (Mr. Gauke). There is not time for them to speak in the debate so they have asked me to speak on behalf of their concerned constituents, too.
	The Secretary of State knows full well how bad the crisis in south-west Hertfordshire is, because we have written to her several times, met her and explained the situation. That crisis is driven by deficits. The cuts and changes that are going on in south-west Hertfordshire are due not to reconfigurationthe new word that the Secretary of State has come up with to defend the cuts in services throughout the countrybut purely and simply to south-west Hertfordshire's huge deficit problem.
	There has been a debate for many years about the services that are to be provided in Hertfordshire, particularly in south-west Hertfordshire. That debate took place before the 1997 general election and has continued since. At a recent Prime Minister's Question Time, I said to the Prime Minister that I agreed that there has been huge investment in West Herts hospitals both before the general election of 1997 and since. Therefore, it is not the case that my part of Hertfordshire has Victorian hospitals that were built 150 years ago and that are decrepit. It is not the case that we do not have a state-of-the-art birthing unitit is closed at present, and being used as offices. It is not the case that we do not have a cardiac unit at the Hemel Hempstead hospital; it is full most of the time. It is not the case that we do not have a stroke unit, which is also full most of the time. It is not the case that we do not have an intensive care unit, whichthe Secretary of State will be surprised to learnis full most of the time. It is not the case that we do not have an excellent accident and emergency centre, which, sadly, has recently been exceeding the four-hour waiting times as so many of our constituents need to go there for their treatment. It is not the case that we do not have or need a high dependency unit, which is closed at present so it is not full. The maternity unit, which was built before the 1997 general election and closed immediately afterwards, is needed and would be used so that we had a consultant-led maternity unit, but it is currently being used as office space.
	Investing in your health was a wonderful catchphrase that was employed before the last general election. Those buzzwords referred to the reconfiguration, closure or movements of services in West Herts, and there was a huge debate about that. There was no consensus at all as to what should happen. The local residents in Hemel clearly did not want to lose their hospital and they voted against that in huge numbers. The people of Watford and the bottom part of south-west Herts did not want to lose Watford general hospital. The people of Welwyn and Hatfield had been promised a huge private finance initiative worth 500 million, so they were happy to lose their existing hospital if they got a new state-of-the-art hospital.
	The promises and proposals before the last general election under Investing in your health were as follows: there would be a brand new PFI hospital in Welwyn and Hatfield and the Queen Elizabeth II hospital would go; the Watford general hospital would have a 350 million PFI project and would be built up; and Hemel would be downgradedalthough I had correspondence from the then Secretary of State and numerous Ministers saying that the accident and emergency unit would remain in Hemel and that the hospital site would be protected.
	Let us explore what has happened since the general election, and since the Secretary of State's decision to come down hard on trusts with funding problems. Those problems are purely to do with the funding formula that the Secretary of State has imposed on the trusts, and if she reads the Select Committee report into deficits she will learn that the Labour-dominated Committee agrees with that comment. Since the general election and the Secretary of State's measure, a decision has been madewhich has nothing to do with clinical care or with greater efficiencies in the way that the health service is run locally, but which is purely to do with financial problemsto close the Hemel Hempstead hospital and to move its acute care services across to Watford, and the 350 million project will not take place so they will be moved into portakabins. The people of St. Albans will have to travel past the Hemel hospital and all the way to Watford, if they are lucky, to get to the nearest accident and emergency unit. That is simply shameful.
	That is frightening my constituents. The Secretary of State has been invited to the constituency time and again. When I was at this year's Conservative party conference, I heard that the Secretary of State was going to come to Hemel. I was so proud; I wanted to show her the excellent hospital, the fantastic staff and the facilities that are about to be closed, and to try to convince her not to do that horrible thing to my constituency. However, when I arrived in Hemel I found that she was not going to visit the hospital; instead she was going to visit a social services department just up the road. A small demonstration of disabled people, mums with pushchairs and elderly people had gathered to express their concerns and to tell the Secretary of State what they were worried about. However, instead of coming through the front gate, the Secretary of State popped over the back fence and went through the back door, to be confronted by some elderly people with Zimmer frames running down the road. That is the sort of image that the Secretary of State left in my constituency.

Michael Penning: If the Secretary of State wants to deny that, she can rise at the Dispatch Box. She does not do so because it is true; that is exactly what happened. Instead of coming along there armed with platitudes and saying, This is all about better care for your constituents and for south-west Hertfordshire, it should be acknowledged that what is happening is all about the fact that there is not the money. I know that that is true, because when I approached my trust's medical director at a recent public meeting and said, Would you make these changes and cuts if it weren't for the deficits? he said, Of course I wouldn't, Mr. Penning. That man is a professional; he is not going to lie to me or mislead me. These cuts and changes are being made because we are not getting a fair deal. The Secretary of State's constituency gets 400 per head more than mine. When giving evidence to the Health Committee, she said that the reason

Stephen O'Brien: It is a great pleasure to follow my hon. Friend the Member for Hemel Hempstead (Mike Penning), who gave one of his most modest and quiet speeches and pulled his punches today. I hope that the Secretary of State realises just how lucky she was to hear only that much of the argument.
	We have had a very good debate, in Opposition time, on the vital issue of what our constituents demand of their NHS, not what this Government are hell-bent on imposing. We remain deeply concerned that this Labour Government's basic reconfiguration of acute hospital services remains rooted in their desperate scramble to mitigate an NHS cash crisis of their own incompetent makinga problem that will intensify when the European working time directive comes into forcerather than in meeting the needs of the English public.
	Let us be clear: as my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) said in his authoritative, measured and responsible opening speech, we are not opposed to change. Indeed, far from standing in the way of changebe it changes to primary angioplasty or stroke services, or reconfiguration itselfour challenge to the Government is that they are arguing for change without producing the clinical, health-based evidence to inform it. Today's reconfiguration is their emergency response to financial pressures of their own making and to the anticipated effects of the European working time directive.
	Where was the evidence? What was the Government's response? Not a scrap of evidence was forthcoming from the Secretary of State in a speech that, sadly for the House, has not improved on its umpteenth outing. Before we get the usual rant from the Minister, during which he reaches back and bypasses a complete decade in which Labour's hands have been on the tiller of the NHS, I hope that he will, for once, debate the real and substantive issues raised about our NHS today.
	We heard just yesterday the latest deficit figures. Almost a third of England's hospital trusts and almost half its primary care trusts are forecast to be in deficit at the end of this financial year. The gross deficit is forecast to be slightly larger than last yearthe cash crisis has not been solvedand Ministers are seeking to create a slush fund by plundering training and other budgets and cutting services. Many organisations are simply pushing costs into the next financial year by putting off orders and payments until April, or by rationing treatment.
	At the beginning of this month, a BBC survey found that a quarter of all PCTs in England are asking patients to wait longer for hospital treatment, and all of us are contending with cuts to front-line patient services in our constituencies, be they podiatry, maternity and physiotherapy services, or occupational and speech therapy services. People do not have to take just the Opposition's word for it. At the beginning of chapter four of its Delivering High-Quality Surgical Services for the Future document, the Royal College of Surgeons has identified the drivers for reconfiguration. It states:
	The reconfiguration of services must have a sound clinical and evidence base. Financial and managerial expediency must not be primary drivers for reconfiguration.
	However, that is exactly what is happening.
	The problem is compounded by the imminent enactment of the European working time directive. The Secretary of State tries from time to time to blamecan you believe it, Mr. Deputy Speaker?the last Conservative Government for poorly negotiating the directive. However, it was case law modifications to the directive, brought about by the SIMAP and Jaegar rulings in 2002 and 2003 respectively, that made it so damaging. It is this Government who have failed to address those issues and continue to drag their feet and bury their head in the sand at the same time, which is some achievement. Lord Hunt, who was recently reappointed, was responsible for this area back in 2004 and he said on the record that if the European working time directive proved to be difficult to implement, he would consider putting off the next round of implementation from 2009 to 2012. I hope that the Minister will respondhe seems to be taking some adviceand tell us whether the Government are considering that delay in the light of the problems that have now been clearly identified.
	We have heard about the need to configure services to the geography of a locality, be that in West Sussex, in a series of powerful interventions from my hon. Friend the Member for Chichester (Mr. Tyrie); in Lancashire, as we heard in the powerful speech by my hon. Friend the Member for Ribble Valley (Mr. Evans); or in Surrey, on whose behalf my hon. Friends the Members for Spelthorne (Mr. Wilshire) and for South-West Surrey (Mr. Hunt) both made clear cases. There are many rural areas that need to rely on those same arguments.
	David Lewis, consultant at the threatenedfor financial reasons, of courseemergency department in Ipswich, has summarised the whole debate. He wrote to my right hon. Friend the Member for Witney (Mr. Cameron) on 5 December, identifying that the Government's problem is that they are seeking to reconfigure services to suit just 3 per cent. of patientsthose who need the specialist super-centres. They should not shut down the accident and emergency units needed by the other 97 per cent. Mr. Lewis asks:
	what will happen to the 97 per cent. of patients without Ischaemic Stroke
	and other such illnesses? He continues:
	Those specific patients may benefit from the longer journey but who is going to sort them from the multitude of others with similar symptoms and signs. These patients do not have their diagnosis written on their forehead when the paramedics arrive. Making these diagnoses is often difficult and requires good quality doctors in local Emergency Departments with local back up of core services in that hospital.
	Labour and their Think Tank (Comfortably situated in London and never more than a few miles from their local well funded Emergency dept) forget about the conditions which will do worse by spending an extra 20-40 mins in the back of an ambulance, eg...cardiac arrhythmia...meningococcal sepsis in children...pulmonary embolism...pelvic fractures.
	Also what will happen to all the other patients we deal with who do not need specialist centres...Broken arms and legs in children...overdoses...gastroenteritis.
	What is actually needed is a realistic assessment of what are the core requirements of a local Emergency Department...By all means let's invest more in super-centres but not at the expense of the only real safety net left in the NHSthe local Emergency Department. Don't expect minor injury centres or emergency care practitioners to take up the slack. We were told this when the GPs stopped being on call for their patients. Local services would apparently take overthis has not happened and there has been a rise in Emergency Department attendances.
	That is not a politician speaking, but a respected senior practitioner in the service. It is time that the Government took note.
	When my right hon. Friend the Member for East Hampshire (Mr. Mates) argues, in a comprehensive speech, for the retention of acute and other NHS services in his area, the Government should listen. My hon. Friend the Member for Mid-Sussex (Mr. Soames), in a superb speech, pointed out that the massive public support that has been engendered in his area rejects the proposals by the Government, the Department and the local NHS. The options are simply a change too far on top of a rash of changes that have been suffered locally. The Government should listen, because the removal of full accident and emergency services from the Princess Royal hospital in Haywards Heath is not acceptable, and it is not what Dr. Alberti wrote.

Stephen O'Brien: No, I will not, because there is limited time.
	There was intervention upon intervention onthe Secretary of State demanding to know how the consultations were anything but a sham when the Government are intent on proceeding with their reconfiguration plans anyway. The powerful consultations that have been taking place up and down the country and that clearly show disagreement with the Government and the Department have had no effect.
	As my hon. Friend the Member for North-East Bedfordshire (Alistair Burt) said, in a speech of great impact, this has taken place against the background of the Government putting in place what Labour ranted against before 1997. The funding formula, especially for county areasnot least in Cheshire, as in Bedfordshiremust be reviewed to establish a new, fair basis. Otherwise, it exacerbates the real financial pressures leading to the non-clinically driven reconfiguration.
	My hon. Friend the Member for South-West Surrey made a strong case and gave the Government the opportunity, if only they would listen, to do the right thing for the people of Surrey, but I fear that they will not listen and that the wrong thing will then proceed. We will continue to argue and not be in any way deterred, as was clear from the powerful speeches of my hon. Friends the Members for Enfield, Southgate (Mr. Burrowes) and for Hemel Hempstead.
	The hon. Member for North Norfolk (Norman Lamb) reinforced many of the powerful arguments made by my hon. Friend the Member for South Cambridgeshire. He failed, however, to give credit to the healthwatch initiative that we have put out as policy, which includes local authority involvementthe very thing that he argues forand the enhancement of the oversight and scrutiny committees. He should find reading those policies profitable, especially when they are contrasted with what the Government have been doing. The Government have sought, once more, to quash the patient and public voice. LINkslocal involvement networkshave been widely discredited, and yet the Government are pushing ahead with them.
	We have also heard from Labour Members, all trying to justify changes to acute services and the health service in their constituencies as reconfigurations on anything other than financial grounds, or grounds related to the European working time directive and staffing issues.

Stephen O'Brien: No, I will not.
	We heard from the hon. Members for Kingswood (Roger Berry), for Crawley (Laura Moffatt), for Dudley, North (Mr. Austin), for Dartford (Dr. Stoate), for Staffordshire, Moorlands (Charlotte Atkins) and for Stockton, North (Frank Cook), but they did not convince. However, the hon. Member for Hartlepool (Mr. Wright), in a dignified and courageous critique of his own Government, which confirmed the sham consultation complaint that we all make, showed how the promise that was made by the Prime Minister at the time of the election to keep the University hospital of Hartlepool has not been honoured. I believe that the hon. Gentleman's interpretation of the IRP, and not the alternative that was offered during the course of the debate, is the one to be supported.
	It is perhaps no surprise that we heard this week that 84 per cent.more than five in sixof the senior civil servants in the Department that is led by the Secretary of State do not believe that it is well managed. That compares with 49 per cent. in the civil service as a whole. Uncannily, three years ago, when the Secretary of State was at the Department of Trade and Industry, only 17 per cent. of officials in the DTI thought that
	our leaders make the right decisions for the long term
	and only 22 per cent. thought that
	our leaders are effective in facing up to difficult issues.
	There is one consistent and common thread: the right hon. Member for Leicester, West (Ms Hewitt). I think that we can draw our own conclusions.
	There is a clear, stark example of poor policy: the Staffordshire ambulance service, which has been put in the departure lounge. I hope that the Government will at last listen and that the Staffordshire ambulance service will not be reduced in quality in order to meet the demands of the West Midlands service.
	We have seen Ministers and Cabinet Ministers running around seeking to defy their own Government policy. That may be collective hypocrisy, rather than collective responsibility, but I hope that at last they will now listen in order to make reconfiguration respond to the demands of patients, rather than simply to act as an emergency outlet for their financial mismanagement.

Andy Burnham: I will read the hon. Gentleman's speech tomorrow in  Hansard, but he should be thoroughly ashamed of it because it bears no relation to the facts on the ground about the national health service today. I would be interested to hear from a consultant who agrees with the speech that the hon. Gentleman made.
	Colleagues have made points about the quality of the consultations that the NHS carries out. I agree with Opposition Members who say that, at times, the NHS needs to raise its game. For that reason, the chief executive of the NHS asked Sir Ian Carruthers to work with strategic health authorities in considering their proposals for service change. That work has been completed, and I am pleased to say that next week we will bring forward its findings, which I am sure will be of interest to every Member. The issue is important, and all colleagues are right to say that we need the highest quality information in the public domain, so that our constituents can make the right judgments on important matters.
	However, there is a responsibility on Members of Parliament, too. If the NHS raises its game and does better at providing consultations, there is a responsibility on Members not to scaremonger, rumourmonger and portray every change as a cut. There is responsibility on all MPs to lead the public debate in their area. Where health changes represent human progress, MPs have a responsibility to back them, but today's debate was all about scaremongering.
	Let me quote a spokesperson for the Royal Cornwall Hospitals NHS Trust responding to a Conservative party press release that said that 29 accident and emergency units were lined up for closure, one of which was run by the trust:
	There is no threat to either the AE or casualty services provided by the trust. Neither the trust nor the PCT were contacted by the Conservative party press office to check the accuracy of their research. We have made it quite clear to them that their statement should not have included reference to RCHT and have asked for it to be retracted. Misrepresentative statements such as these are upsetting not only to our staff members but also because of their potential to lead to unnecessary scaremongering and concern among our local community.

Andy Burnham: That is what the Opposition are doing. They are creating websites and setting up campaigns, but since the press release it has been established that there were no plans to change the accident and emergency services in 12 of those29 hospitals.

Gordon Banks: Thank you, Mr. Deputy Speaker, for allowing me the opportunity to have this debate on an issue that has knowingly affected my life for the past seven or eight years, and unknowingly has affected my whole life. I should also like to thank my right hon. Friend the Minister for being in her place to reply.
	Coeliac disease is not simply a food allergy, and sufferers are not just fussy eaters. It is an auto-immune disease caused by gluten intolerance that can cause severe symptoms. Gluten is a protein found in wheat, barley and rye. The gluten component damages the gut, preventing normal digestion and absorption of food and therefore vital minerals and nutrients. If it is left undiagnosed, it can lead to life-threatening illnesses such as bowel cancer, as well as other serious conditions, including osteoporosis and infertility.
	Unfortunately, sufferers are born with the condition due to genetic disposition, and symptoms can be triggered at any time. For me, that happened when I was 44; I know that many hon. and right hon. Members will struggle to believe that I have exceeded 44 years of age as they look at me tonight. Coeliac disease can be treated effectively and simply by changing to a gluten-free diet, however, but in society there still appears to be a lack of knowledge regarding the disease. That applies to the general public, and more worryingly, to health care professionals, as well as to politicians. On asking anyone who has been diagnosed late in life, as I was, one will hear a catalogue of medical errors and misdiagnosis. Some of these stories would make people's hair curl; mine was made to fall out.
	I look back and I clearly see symptoms that were being wrongly diagnosed. Alarmingly, diagnosis rates are very low. Seven out of every eight people who have the illness are unaware of it. Symptoms vary, ranging from bloating, diarrhoea, nausea, weight loss and depression to hair loss, which I mentioned. It is those varying symptoms that obviously add to the confusion in the diagnostic process, as coeliac disease is not high on the radar of either GPs or specialists. I want to focus on better diagnosis in my speech tonight. There is a great need to have a better system of diagnosis to ensure that sufferers can have a better quality of life. Early diagnosis is the key. Kids cannot give of their best if they are ill; they cannot work in the classroom if they are stuck in the toilets. That is not good enough for our children, and it is certainly not good enough for the future of the UK.
	A 2006 survey carried out by Coeliac UK discovered that the average age for diagnosis is 41.3 years and that the average duration of symptoms prior to diagnosis is 13.1 years. I am sure that hon. Members would agree that more needs to be done to remove those 13 years of suffering and the worry that accompanies them.
	I can add a personal account on this matter. It took me about 10 years of going back and forth to my doctor to be diagnosed. I have apparently had stomach ulcers and irritable bowel syndrome, and I was also told that my problems could be related to stomach cancer. That is a set of conditions that even a hypochondriac could not have dreamt up. However, as hon. Members may have guessed, they were clearly the result of misdiagnosis. That is a prime example of where GPs and specialists have been unable to recognise the symptoms placed in front of them. I am not saying that that applies to all medical practitioners. Funnily enough, when I visited a particular specialist for the first time after yet another referral from my GP, he thought that I had coeliac disease after I had spoken to him for two minutes. There is knowledge on the disease, but it must be spread much more widely in the medical community.
	There is still a responsibility on society as a whole to recognise the symptoms, however, and it is our job to raise awareness and promote the facilities that can diagnose the disease. For example, the Biocard test that is made by Adastra Medical, which will be available over the counter at Boots the Chemist in May, is a quick and relatively cheap way of testing for coeliac disease. That pin-prick test, which has a 97 per cent. accuracy rate, could save the NHS future costs in treatment of infertility, osteoporosis and cancer. Let us be clear: some of the solutions are not too difficult, but the rewards are great.
	As well as the obvious health implications, coeliac sufferers must overcome other barriers that can arise in society. In recent discussions with coeliac sufferers, we have learned of the difficulties that many have faced in being accepted into the armed forces and the police. Written answers to my questions in the House have not necessarily shed any light on that. However, I was pleased to have had a discussion with the Minister with responsibility for disabled people, my hon. Friend the Member for Stirling (Mrs. McGuire), and with Sarah Sleet from Coeliac UK regarding the implications that disability discrimination legislation may have in that respect.
	Coeliac disease also has implications for our economy. Those who took part in the 2006 survey highlighted an average of 21.4 days off work prior to diagnosis. Post-diagnosis, that fell to an average of 3.6 days per year, so there are clearly economic advantages to be gained from early diagnosis.
	Some progress has been made but there is still a long way to go. Hon. Members may have noticed that in Westminster we have a good standard of menu labelling, but, believe it or not, there is life outside the Westminster bubble.

Gordon Banks: The hon. Gentleman makes a valuable point that I shall come to later.
	Going back to the Westminster bubble, the progress that has been made here since May 2005 needs to extend further out into the wider communityinto bars, restaurants and shops nationally. Trips to the supermarket can take hours when it is necessary to study the packages of almost everything that one buys. New European directives that came into force in November 2005 make it mandatory for all food ingredients to be listed on packaged food, but we can go further to ensure that the advice is clearly labelled, not merely in very small print on the back of the package.
	In October 2005, the all-party parliamentary group on coeliac disease and dermatitis herpetiformis was formed with the help of my hon. Friend the Member for North Durham (Mr. Jones), the hon. Member for Daventry (Mr. Boswell) and Lords Bilston and Brookman. The group brings together Members who have an understanding of the condition and want to be involved in the work on it. Last May, I tabled early-day motion 2127 to raise awareness of it. It received 144 signatures, thus highlighting that it was an issue that MPs were concerned about, even if few had a real understanding of it.
	Moving on to the point made by the hon. Member for Daventry, this Session I have tabled early-day motion 276, which currently has attracted 124 signatures. I take this opportunity to urge other hon. Members to add their name to it. Members of the all-party group and coeliac sufferers are worried that certain primary care trusts are restricting the supply via prescription of gluten-free foods. Those actions appear to be cost-driven, not care-driven, and they have no place in a modern and progressive NHS. We recognise that many gluten-free foods and ingredients are significantly more expensive than regular foodstuffs. For example, gluten-free flour is about five times more expensive than regular flour. With a gluten-free loaf of bread costing about 2, even a Member who never does the weekly shop will appreciate that that is very expensive for a loaf of bread. However, those goods are not free on prescription for coeliac sufferers unless they are exempt from prescription charges for other reasons. I, and around 91 per cent. of Coeliac UK members, find prescriptions essential for our dietary management. Primary care trusts should not pass on the cost to other patients, certainly not those who cannot afford it.
	The goods need to be prescribed by a GP who understands the volume of products required to ensure that people with busy lives are not expected to treat their GP's surgery as a grocer's store and thus add to the GP's pressures.
	As I said, coeliac disease also has a cultural and social dimension. In the 2006 survey, 67 per cent. of respondents said that they were less likely to eat a meal outside their homes since diagnosis. That figure would be greatly reduced through better labelling on foodstuffs and menus. For too many, eating out is a minefield, but better diagnosis and information can act as a minesweeper, ensuring that people live the life that they want and not the life that they feel that their illness allows.
	Coeliac disease is a health issue, but people also need to be educated better about it. As politicians, we must help to raise awareness, and that has been done to some extent in recent years. Some of that progress can be attributed to the excellent work and dedication of Sarah Sleet and the team at Coeliac UK. I hope that our all-party group, and a similar organisation in the Scottish Parliament, can work with Coeliac UK to add to that awareness.
	Last week, a hugely productive debate took place in the Scottish Parliament to which I was pleased to see that so many Members contributed. The Coeliac UK information stand was pleased to welcome prominent politicians such as Scotland's First Minister, Jack McConnell, Minister for Health and Community Care, Andy Kerr and Presiding Officer, George Reid. It was interesting to hear the personal accounts of MSPs and that of Yvonne Murray, with whom hon. Members who follow athletics may be familiar.
	Yvonne spoke about her daughter, who is a coeliac sufferer and weighed only 20 lb when she was three years old. She related other distressing tales about her daughterthings that no one would wish on any child. Yvonne's background highlights that she is clearly a determined individual, but we cannot expect everyone to be that determined. After all, not many people have the courage to stand up to their doctor to say that the doctor's diagnosis of their child's condition is wrong.
	Awareness and ease of testing alleviates speculation and misery, avoids hearsay and provides a quick answer. Unfortunately, serious consequences are sometimes associated with coeliac disease. For example, an elderly woman sadly passed away after developing bowel cancer as a result of misdiagnosed coeliac disease. Another elderly woman was admitted to hospital in Scotland in a neighbouring constituency to mine from a care home. Despite informing the hospital of her coeliac condition, people from the home found her on two consecutive nights sitting in bed eating toast. I hope that those examples give the Department of Health an impetus to examine the issues more closely. I also ask that, when possible, representatives of the Department consult the all-party group, and Coeliac UK at approaching functions.

Gordon Banks: My hon. Friend is right. Diagnosis is the be all and end all. The later the diagnosis, the worse the condition and the worse the implications for other conditions that are likely to be inherited as a result of coeliac disease. I hope that the Minister will take away some information about the Adastra test and come back to us another time to tell us her view of its suitability in the NHS.
	Returning to my point about the Department of Health and Ministers working closely with Coeliac UK and, indeed, the all-party group, we have a reception in the terraced pavilion on 15 May this year as part of coeliac awareness week. I would like to take this opportunity personally to extend an invitation to the Minister to come along and make a valuable contribution to that dayand she can even bring her Parliamentary Private Secretary along.
	As I mentioned earlier, Coeliac UK is a prime leader and it continues to fund research projects into the disease. It is currently investing about 760,000 in projects based at Imperial college, London, Southampton university and City hospital in Birmingham. It is my hope that that work and this debate will help raise awareness and also help to provide the impetus to help my right hon. Friend and her colleagues in the Department of Health to look at the issues raised and deliver solutions that will benefit the large number of coeliac sufferers.

Andy Reed: I am grateful to my hon. Friend for giving way. Speaking as someone with a family member who suffers from coeliac disease, I am very aware of the issues that have been raised this evening. Before my hon. Friend finishes, will he expand on how we can perhaps extend awareness further? Clearly, the diagnosis time of about 13.6 years is too long, especially when we know that early diagnosis makes a significant difference. Wehave heard about coeliac awareness weekand how the Minister would be welcome to come along to the receptionbut how much further work could the Department do to ensure that every GP is made aware of this disease and has the diagnostic tools available so that early diagnosis can take place and reduce the length of the suffering?

Kevan Jones: I start by congratulating my hon. Friend on securing this debate and I declare my interest as the chair of the all-party coeliac disease and dermatitis herpetiformis group. I also declare an interest in being a coeliac sufferer myself. I was diagnosed only five years ago, like my hon. Friend, and after major stomach surgery. I have to say that a gluten-free diet has changed my life, as it did my hon. Friend's, particularly in regard to the symptoms that I previously had. I also stress that a gluten-free diet is not a lifestyle choice or some new Hollywood-type fad diet, but something that we coeliac sufferers need strictly to abide by. My symptoms included tiredness, depression and abdominal pain, but there is also real concern when you do not know what is wrong with youand the stress that that can cause an individual should not be underestimated.
	I am pleased that awareness is being raised, albeit slowly, and I give credit to the House authorities, which co-operated very closely with the all-party group to have food properly labelled in this place. I would also like to congratulate certain supermarkets, such as Sainsbury's, which is very good with food labelling, as well as providing gluten-free alternatives. Even the airline industry has slowly come round to the fact that coeliac sufferers exist, although I always find it strange that when I have a gluton-free meal on British Airways, the air stewardess offers me bread with it. The one thing that I miss is a pint of beer, which I have not been able to enjoy now for about five years, though my hon. Friend tells me that there are some very good alternatives to it.
	I finish by saying this. The hon. Member for Daventry (Mr. Boswell) referred earlier to prescription, which is vital. It is a crippling disease for the sufferers, and let us not forget the parents of children who suffer from coeliac disease. Those on a limited income cannot afford the expensive alternatives to bread and other foods. Those foods are not luxuries; they are the staples that most people take for granted and buy every day in the supermarkets.
	I am pleased that this debate has taken place today. Let us hope that it adds a little more to people's understanding of coeliac disease, which is more common that we like to think.

Rosie Winterton: I congratulate my hon. Friend the Member for Ochil and South Perthshire (Gordon Banks) on securing this debate. I have to say that this is one of the best attended end-of-sitting debates that I have responded to. I am also pleased to have heard the contributions of the hon. Member for Daventry (Mr. Boswell) and from my hon. Friends the Members for Pudsey (Mr. Truswell), for North Durham (Mr. Jones) and for Loughborough (Mr. Reed). They have demonstrated the extent of the concern that exists in the House about this matter, and also the success of the all-party group, which is vital for raising public awareness of the issues that affect those who live with coeliac disease.
	It would be nice to have another hour to debate the points that have been made in all those contributions, but I will try to address as many of them as possible in the remaining time. It is good news that this matter is also being debated in the Scottish Parliament, and that the devolved Administrations are looking at the issue. I would like to pay tribute to Coeliac UK, and particularly to Sarah Sleet. They play such an important role in improving the lives of people with coeliac disease through support, campaigning and research at national level and, importantly, at local level. I might say more about that when I go on to talk about prescribing.
	My hon. Friend the Member for Ochil and South Perthshire graphically and movingly described the problems that people face if they are not diagnosed early. It is vital that GPs are able to recognise the early symptoms of the condition, although we need to face the fact that it can sometimes be difficult to recognise it, as its symptoms can be similar to those of other conditions. Raising the profile of coeliac disease with the medical profession, and particularly with GPs, is therefore vital, and the work that Coeliac UK and the all-party group are doing can help to achieve that.
	That is also why the Department of Health set up Prodigy, an online, up-to-date and interactive decision support system. It is a source of clinical knowledge that can help health care professionals and patients to manage the common conditions generally seen in primary and first-contact care. The sections of Prodigy devoted to the diagnosis, treatment and management of coeliac disease expressly recommend Coeliac UK as a source of information and support.
	The Primary Care Society for Gastroenterology last year revised and issued guidelines on the recognition, diagnosis and management of coeliac disease. They are designed to assist the NHS in achieving earlier diagnosis, and they include the latest information on the clinical features, diagnosis and management of the disease. My hon. Friend and others made a point about the Biocard testing kits. While we of course welcome any new tools that can help to get more people diagnosed, it must be recognised that self-testing kits should not replace a medical diagnosis, and that anyone experiencing symptoms of coeliac disease should seek the advice of their doctor. It is important to get that point across.
	In relation to raising awareness among the general public, NHS Direct, NHS Direct Online and NHS Direct Interactive have been established to provide advice and information on health and self-care. We can therefore ensure that people have access to information on conditions and illnesses such as coeliac disease. I am glad that my hon. Friend the Member for Ochil and South Perthshire has had a meeting with my hon. Friend the Minister with responsibility for disabled people to examine ways in which awareness can be raised in different Departments.
	The type of principles set out by the Department of Health in its national service framework on long-term conditions would apply to people with coeliac disease. I am aware, however, that medication is not always relevant to the condition, and that a gluten-free diet is often the answer.
	Correct diet is essential to control of the condition and, as has been pointed out, such a diet can be much more expensive than an ordinary diet. Gluten-free products are now available on prescription to ensure that people with the disease can obtain staple foods. We fully expect GPs who prescribe gluten-free products to assess the dietary requirements of individual patients, taking into account not only their nutritional requirements but their lifestyle and needs. It is true that the survey conducted by Coeliac UK in 2002 found that more than 90 per cent. of people with the disease obtained some gluten-free food on prescription.
	However, I appreciate the concerns raised by Members that changes to local prescribing policies mean that some PCTs may not be fully meeting the dietary needs of their patients. I know that the position in Northampton is being reviewed in April, and that Coeliac UK has done a lot of work with PCTs in others areas to highlight some of the problems. That has had an effect on local decisions. We certainly expect the provision of food items to be based on individual need, not on a preconceived idea of what someone ought to receive.
	The Advisory Committee on Borderline Substances was set up in 1971 to advise GPs on the prescription of products such as foodstuffs. It has now become the NHS Purchasing and Supply Agency. Later in the year, a review will be carried out of the remit, membership and functioning of the body to make sure that it meets some of the NHS's changing needs, and this area may be one of those considered.
	With regard to food labelling and prescribing of foods, obviously, prescribed foods will represent a small proportion of an individual's diet. As my hon. Friend the Member for Ochil and South Perthshire said, coeliac disease sufferers buy the majority of their food from high street shops, like everyone else. It is therefore important that food labelling be comprehensive and reliable. I think that it has got better in recent years.
	Again, Coeliac UK provides quarterly updates on products, which is extremely helpful for sufferers. The Food Standards Agency has strengthened food labelling rules to help people to avoid certain ingredients, but I know that, with coeliac disease, there can be issues around, for example, the production process if flour is used. That is important. I will talk to the Minister of State, Department of Health, my hon. Friend the Member for Don Valley (Caroline Flint), about some of the issues that have been raised with regard to labelling.
	I thank my hon. Friend the Member for Ochil and South Perthshire for the invitation to the reception, which I certainly hope to attend. I hope to reflect the support that the Government give to the work of the all-party group and to Coeliac UK, and to help to continue to raise awareness of the issue in the House and outside.
	 The motion having been made at fifteen minutes past Seven o'clock, and the debate having continued for half an hour, Mr. Deputy Speaker  adjourned the House without Question put, pursuant to the Standing Order.
	 Adjourned at fifteen minutes to Eight o'clock.